Healthcare Provider Details

I. General information

NPI: 1669909511
Provider Name (Legal Business Name): PARK CITY PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 SIDEWINDER DR. STE 102
PARK CITY UT
84060-7518
US

IV. Provider business mailing address

PO BOX 970309
OREM UT
84097-0309
US

V. Phone/Fax

Practice location:
  • Phone: 435-649-9492
  • Fax: 801-692-9083
Mailing address:
  • Phone: 801-691-1701
  • Fax: 801-335-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number352590747
License Number StateUT

VIII. Authorized Official

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