Healthcare Provider Details

I. General information

NPI: 1801916309
Provider Name (Legal Business Name): FELLER ORTHODONTICS A PROFESSIONAL ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 E 3300 S
SALT LAKE CITY UT
84109-2737
US

IV. Provider business mailing address

2505 E 3300 S
SALT LAKE CITY UT
84109-2737
US

V. Phone/Fax

Practice location:
  • Phone: 801-466-0040
  • Fax:
Mailing address:
  • Phone: 801-466-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number138264-9921
License Number StateUT

VIII. Authorized Official

Name: DR. PARLEY JACK FELLER
Title or Position: OWNER AND ORTHODONTIST
Credential: DDS
Phone: 801-466-0040