Provider Demographics
NPI:1396893012
Name:PDC PROVO LLC
Entity type:Organization
Organization Name:PDC PROVO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-426-6255
Mailing Address - Street 1:2520 N UNIV AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-426-6255
Mailing Address - Fax:801-224-2966
Practice Address - Street 1:2520 N UNIV AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-426-6255
Practice Address - Fax:801-224-2966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLATINUM DENTAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT31921223G0001X
UT6026130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529113131001Medicaid