Healthcare Provider Details

I. General information

NPI: 1548330004
Provider Name (Legal Business Name): ROBERT WADE FERRELL DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 N 500 W
PROVO UT
84601-1547
US

IV. Provider business mailing address

1508 E SKYLINE DR SUITE #300
OGDEN UT
84405-4846
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-8002
  • Fax:
Mailing address:
  • Phone: 801-334-9258
  • Fax: 801-334-9273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number350703
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberS4-138C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: