MEDICARE: PDC RIVERTON LLC

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	1223P0221X	Pediatric Dentistry
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1306291422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PDC RIVERTON LLC

Provider Business Mailing Address
First Line	:	2476 N UNIVERSITY PKWY STE 201
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3869
Country	:	US
Telephone Number	:	801-305-3460
Fax Number	:	801-692-9083

Provider Business Practice Location Address
First Line	:	2364 W 12600 S
Second Line	:	STE 1A
City	:	RIVERTON
State	:	UT
Zip	:	84065-7109
Country	:	US
Telephone Number	:	801-253-8866
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE COORDINATOR
Name	:	TAELOR JEPPSON
Credential	:
Telephone Number	:	801-305-3460

Provider Enumeration Date	:	04/26/2016
Last Update Date	:	04/26/2016

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Directions to “PDC RIVERTON LLC ” Practice Location

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