Healthcare Provider Details

I. General information

NPI: 1730586355
Provider Name (Legal Business Name): JUAN C. CHAVEZ, D.M.D., P.L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 N UNIVERSITY AVE STE 101
PROVO UT
84604-6081
US

IV. Provider business mailing address

2520 N UNIVERSITY AVE STE 101
PROVO UT
84604-6081
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3104344
License Number StateUT

VIII. Authorized Official

Name: MRS. JESSIE L KITCHEN
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 801-305-3460