Healthcare Provider Details

I. General information

NPI: 1194201467
Provider Name (Legal Business Name): PATRICK KUNKEL D.D.S., M.S.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 W 9000 S
SANDY UT
84070-2580
US

IV. Provider business mailing address

826 SPRING MILL LN
INDIANAPOLIS IN
46260-3535
US

V. Phone/Fax

Practice location:
  • Phone: 385-900-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10796726-9921
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number-12012388A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: