Provider Demographics
NPI:1487381851
Name:LONGFELLOW, KIRT DALLAS (DMD)
Entity type:Individual
Prefix:
First Name:KIRT
Middle Name:DALLAS
Last Name:LONGFELLOW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 N 2000 W STE G
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8215
Mailing Address - Country:US
Mailing Address - Phone:801-771-8000
Mailing Address - Fax:
Practice Address - Street 1:1737 N 2000 W STE G
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8215
Practice Address - Country:US
Practice Address - Phone:801-771-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12949750-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice