Healthcare Provider Details

I. General information

NPI: 1649837337
Provider Name (Legal Business Name): NORTH LOGAN PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 N 400 E STE 3A
LOGAN UT
84341-7564
US

IV. Provider business mailing address

PO BOX 970184
OREM UT
84097-0309
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-1699
  • Fax:
Mailing address:
  • Phone: 901-305-3460
  • Fax: 801-335-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

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