Provider Demographics
NPI:1013358449
Name:STANSBURY DENTAL AND IMPLANT CENTER PDC PLLC
Entity Type:Organization
Organization Name:STANSBURY DENTAL AND IMPLANT CENTER PDC PLLC
Other - Org Name:STANSBURY DENTAL AND IMPLANT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-691-1701
Mailing Address - Street 1:PO BOX 970596
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-0309
Mailing Address - Country:US
Mailing Address - Phone:801-305-3460
Mailing Address - Fax:801-335-6551
Practice Address - Street 1:263 COUNTRY CLUB DR.
Practice Address - Street 2:SUITE 103
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9600
Practice Address - Country:US
Practice Address - Phone:432-882-2850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT341237122300000X
122300000X, 1223P0300X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty