Healthcare Provider Details

I. General information

NPI: 1225673429
Provider Name (Legal Business Name): MOUNTAIN VIEW DENTAL PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6783 S REDWOOD RD #201
SOUTH JORDAN UT
84084-5743
US

IV. Provider business mailing address

PO BOX 970057
OREM UT
84097-0309
US

V. Phone/Fax

Practice location:
  • Phone: 801-969-8200
  • Fax:
Mailing address:
  • Phone: 801-305-3460
  • Fax: 801-335-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
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