MEDICARE: PDC ALTITUDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1053738989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PDC ALTITUDE

Provider Business Mailing Address
First Line	:	2011 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3613
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3613
Country	:	US
Telephone Number	:	801-305-3460
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. VINCE DILLEY
Credential	:
Telephone Number	:	801-305-3460

Provider Enumeration Date	:	03/28/2014
Last Update Date	:	03/28/2014

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Directions to “PDC ALTITUDE ” Practice Location

Language	Start Address	Practice Location

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