Individual
DR. KELLY A FADDIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
11760 S 700 E, #110, DRAPER, UT 84020-6604
(801) 571-6688
(801) 571-7787
Mailing address
11760 S 700 E, #110, DRAPER, UT 84020-6604
(801) 571-6688
(801) 571-7787
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
144920-9922
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
87-0581297
FEDERAL ID #
UT
Enumeration date
06/11/2006
Last updated
05/31/2011
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