Healthcare Provider Details

I. General information

NPI: 1538946207
Provider Name (Legal Business Name): SOUTH PROVO PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 E VALLEY VISTA WAY
PROVO UT
84606-5636
US

IV. Provider business mailing address

PO BOX 970185
OREM UT
84097-0185
US

V. Phone/Fax

Practice location:
  • Phone: 385-412-6964
  • Fax: 385-248-5034
Mailing address:
  • Phone: 801-691-1701
  • Fax: 801-355-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VIVIAN BETANCOURT
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 801-305-3465