Healthcare Provider Details

I. General information

NPI: 1306291422
Provider Name (Legal Business Name): PDC RIVERTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2364 W 12600 S STE 1A
RIVERTON UT
84065-7109
US

IV. Provider business mailing address

2476 N UNIVERSITY PKWY STE 201
PROVO UT
84604-3869
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-8866
  • Fax:
Mailing address:
  • Phone: 801-305-3460
  • Fax: 801-692-9083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TAELOR JEPPSON
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 801-305-3460