Healthcare Provider Details

I. General information

NPI: 1457801078
Provider Name (Legal Business Name): LOGAN PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 E 200 N STE 3
LOGAN UT
84321-4049
US

IV. Provider business mailing address

PO BOX 970924
OREM UT
84097-0924
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-3689
  • Fax: 435-752-8217
Mailing address:
  • Phone: 801-691-1701
  • Fax: 801-335-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number289803-9923
License Number StateUT

VIII. Authorized Official

Name: JACOB WARNER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 801-691-1701