Healthcare Provider Details

I. General information

NPI: 1467135822
Provider Name (Legal Business Name): PROVO PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 N UNIVERSITY PKWY STE 39
PROVO UT
84604-1503
US

IV. Provider business mailing address

PO BOX 970176
OREM UT
84097-0119
US

V. Phone/Fax

Practice location:
  • Phone: 801-426-6255
  • Fax: 801-734-3714
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JUAN CHAVEZ
Title or Position: OWNER
Credential: DMD
Phone: 801-691-1701