Healthcare Provider Details

I. General information

NPI: 1316315369
Provider Name (Legal Business Name): M KELLY SOUTAS DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S MAIN ST STE 302
SPRINGVILLE UT
84663-2279
US

IV. Provider business mailing address

485 S MAIN ST STE 302
SPRINGVILLE UT
84663-2279
US

V. Phone/Fax

Practice location:
  • Phone: 801-489-6811
  • Fax: 801-489-6840
Mailing address:
  • Phone: 801-489-6811
  • Fax: 801-489-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number374892
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL KELLY SOUTAS
Title or Position: PRESIDENT
Credential: DMD
Phone: 801-489-6811