Provider Demographics
NPI:1316315369
Name:M KELLY SOUTAS DMD PC
Entity type:Organization
Organization Name:M KELLY SOUTAS DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:SOUTAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-489-6811
Mailing Address - Street 1:485 S MAIN ST
Mailing Address - Street 2:STE 302
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2279
Mailing Address - Country:US
Mailing Address - Phone:801-489-6811
Mailing Address - Fax:801-489-6840
Practice Address - Street 1:485 S MAIN ST
Practice Address - Street 2:STE 302
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-2279
Practice Address - Country:US
Practice Address - Phone:801-489-6811
Practice Address - Fax:801-489-6840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
UT374892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty