Healthcare Provider Details

I. General information

NPI: 1336706043
Provider Name (Legal Business Name): SOUTH JORDAN PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10458 S REDWOOD RD
SOUTH JORDAN UT
84095-8501
US

IV. Provider business mailing address

PO BOX 970113
OREM UT
84097-0309
US

V. Phone/Fax

Practice location:
  • Phone: 801-302-8989
  • Fax:
Mailing address:
  • Phone: 801-305-3460
  • Fax: 801-335-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN CARLOS CHAVEZ
Title or Position: OWNER
Credential: DMD
Phone: 801-302-8989