Healthcare Provider Details

I. General information

NPI: 1396490314
Provider Name (Legal Business Name): PROVO PREMIER DENTAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N 500 W STE 204
PROVO UT
84601-1597
US

IV. Provider business mailing address

247 W 2230 N STE 101
PROVO UT
84604-7582
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-2182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DAVID SMITH
Title or Position: OWNER
Credential: DDS
Phone: 801-375-1414