Healthcare Provider Details

I. General information

NPI: 1124438916
Provider Name (Legal Business Name): SLC PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1963 S 1200 E STE 103
SALT LAKE CITY UT
84105-3523
US

IV. Provider business mailing address

PO BOX 970687
OREM UT
84097-0687
US

V. Phone/Fax

Practice location:
  • Phone: 801-466-1212
  • Fax: 801-466-1919
Mailing address:
  • Phone: 801-691-1701
  • Fax: 801-335-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JACOB WARNER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 801-691-1701