1124438916 NPI number — SLC PDC PLLC

Table of content: (NPI 1124438916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124438916 NPI number — SLC PDC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SLC PDC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PLATINUM DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124438916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 970687
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREM
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84097-0687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-691-1701
Provider Business Mailing Address Fax Number:
801-335-6551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1963 S 1200 E
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84105-3523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-466-1212
Provider Business Practice Location Address Fax Number:
801-466-1919
Provider Enumeration Date:
05/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WARNER
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
801-691-1701

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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