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General NPI Number Information
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NPI Number | 1770842593
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Entity Type | Organization
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Legal Business Name | EDDIE FADDIS, DDS, PC
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Dates
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Enumeration Date | 05/14/2012
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Last Update Date | 12/11/2015
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Provider Practice Location Address
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Address Line | 533 W STATE RD STE 202
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-2114
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Country | US
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Telephone | 801-785-8835
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Fax | 801-785-9629
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Provider Business Mailing Address
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Address Line | 533 W STATE RD STE 202
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-2114
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Country | US
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Telephone | 801-785-8835
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Fax | 801-785-9629
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Authorized Official
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Title or Position | PRESIDENT
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Name | EDDIE FADDIS
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Credential | DDS
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Telephone | 801-785-8835
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 145625
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License Number State | UT
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