Healthcare Provider Details

I. General information

NPI: 1265037014
Provider Name (Legal Business Name): K B DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 EAST FORT UNION BLVD, SUITE 101
MIDVALE UT
84047
US

IV. Provider business mailing address

204 EAST FORT UNION BLVD, SUITE 101
MIDVALE UT
84047
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-3578
  • Fax: 801-210-7628
Mailing address:
  • Phone: 801-255-3578
  • Fax: 801-210-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE W. DIMOND
Title or Position: DENTIST
Credential: DDS
Phone: 801-255-3578