Provider Demographics
NPI:1396886511
Name:FADDIS, EDDIE S (DDS)
Entity type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:S
Last Name:FADDIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 W STATE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2116
Mailing Address - Country:US
Mailing Address - Phone:801-785-8835
Mailing Address - Fax:801-785-9629
Practice Address - Street 1:533 W STATE RD STE 202
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2116
Practice Address - Country:US
Practice Address - Phone:801-785-8835
Practice Address - Fax:801-785-9629
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1456251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice