MEDICARE: ANGELA KERR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	80140139922	UT

General Provider Information

NPI Number	:	1710272851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA KERR

Provider Business Mailing Address
First Line	:	2114 FORT UNION BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2114 FORT UNION BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3142
Country	:	US
Telephone Number	:	801-943-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	06/16/2011

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