Provider Demographics
NPI:1588043780
Name:WEST JORDAN PDC LLC
Entity Type:Organization
Organization Name:WEST JORDAN PDC LLC
Other - Org Name:PLATINUM DENTAL CARE
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 970874
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-0687
Mailing Address - Country:US
Mailing Address - Phone:801-691-1701
Mailing Address - Fax:801-335-6551
Practice Address - Street 1:7555 CENTER VIEW CT
Practice Address - Street 2:STE 104
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084
Practice Address - Country:US
Practice Address - Phone:801-566-8540
Practice Address - Fax:801-282-5114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7702761-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty