Provider Demographics
NPI:1457801078
Name:LOGAN PDC PLLC
Entity Type:Organization
Organization Name:LOGAN PDC PLLC
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 970924
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-0924
Mailing Address - Country:US
Mailing Address - Phone:801-691-1701
Mailing Address - Fax:801-335-6551
Practice Address - Street 1:167 E 200 N
Practice Address - Street 2:STE 3
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4049
Practice Address - Country:US
Practice Address - Phone:435-752-3689
Practice Address - Fax:435-752-8217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT289803-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty