MEDICARE: KELLY D. CARROLL D.D.S., PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1710450655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY D. CARROLL D.D.S., PC

Provider Business Mailing Address
First Line	:	2114 E FORT UNION BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3142
Country	:	US
Telephone Number	:	801-943-2020
Fax Number	:	801-943-3394

Provider Business Practice Location Address
First Line	:	2114 E FORT UNION BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3142
Country	:	US
Telephone Number	:	801-943-2020
Fax Number	:	801-943-3394

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KIM HICKEN
Credential	:
Telephone Number	:	801-943-2020

Provider Enumeration Date	:	01/03/2019
Last Update Date	:	01/03/2019

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