Healthcare Provider Details

I. General information

NPI: 1750778072
Provider Name (Legal Business Name): KIP MICHAEL-DAVID FRITZ STERLING D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 05/24/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 200 N STE G
LOGAN UT
84321-4036
US

IV. Provider business mailing address

150 E 200 N STE G
LOGAN UT
84321-4036
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-7668
  • Fax:
Mailing address:
  • Phone: 435-753-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9177
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number11897186-9922
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: