Healthcare Provider Details

I. General information

NPI: 1730658071
Provider Name (Legal Business Name): KAYSVILLE FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 E CRESTWOOD RD STE 5
KAYSVILLE UT
84037-1445
US

IV. Provider business mailing address

47 E CRESTWOOD RD STE 5
KAYSVILLE UT
84037-1445
US

V. Phone/Fax

Practice location:
  • Phone: 801-546-2439
  • Fax: 801-546-0759
Mailing address:
  • Phone: 801-546-2439
  • Fax: 801-546-0759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHERYL KIPPEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-546-2439