Provider Demographics
NPI:1649894486
Name:SOUTH OGEN PDC PLLC
Entity type:Organization
Organization Name:SOUTH OGEN PDC PLLC
Other - Org Name:
Other - Org Type:
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 970328
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:801-476-1234
Mailing Address - Fax:
Practice Address - Street 1:5300 ADAMS AVE PKWY
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6902
Practice Address - Country:US
Practice Address - Phone:801-476-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-06
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty