Individual
KELLAN CLARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2792 S 5600 W, WEST VALLEY CITY, UT 84120-5590
(801) 204-9889
Mailing address
1506 S 900 E, SALT LAKE CITY, UT 84105-2306
(406) 597-7291
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
11782184-9922
UT
Other
Enumeration date
07/16/2020
Last updated
07/16/2020
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