Healthcare Provider Details

I. General information

NPI: 1306506167
Provider Name (Legal Business Name): TOOELE PDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 N MAIN ST
TOOELE UT
84074-1616
US

IV. Provider business mailing address

PO BOX 970353
OREM UT
84097-0353
US

V. Phone/Fax

Practice location:
  • Phone: 435-248-0825
  • Fax: 435-843-5490
Mailing address:
  • Phone: 435-248-0825
  • Fax: 435-843-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

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