Healthcare Provider Details

I. General information

NPI: 1396893012
Provider Name (Legal Business Name): PDC PROVO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 N UNIV AVE SUITE 101
PROVO UT
84604
US

IV. Provider business mailing address

2520 N UNIV AVE SUITE 101
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-426-6255
  • Fax: 801-224-2966
Mailing address:
  • Phone: 801-426-6255
  • Fax: 801-224-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6026130
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3192
License Number StateUT

VIII. Authorized Official

Name: AMBER JOHNSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-426-6255