Healthcare Provider Details

I. General information

NPI: 1154497873
Provider Name (Legal Business Name): KELLY E OBRIEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S 900 E
SALT LAKE CITY UT
84102-4113
US

IV. Provider business mailing address

107 S 900 E
SALT LAKE CITY UT
84102-4113
US

V. Phone/Fax

Practice location:
  • Phone: 801-328-2803
  • Fax: 801-328-2813
Mailing address:
  • Phone: 801-328-2803
  • Fax: 801-328-2813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number03755449922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: