1306291422 NPI number — PDC RIVERTON LLC

Table of content: (NPI 1306291422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306291422 NPI number — PDC RIVERTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PDC RIVERTON LLC
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:
1306291422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2476 N UNIVERSITY PKWY STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-3869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-305-3460
Provider Business Mailing Address Fax Number:
801-692-9083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2364 W 12600 S
Provider Second Line Business Practice Location Address:
STE 1A
Provider Business Practice Location Address City Name:
RIVERTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84065-7109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-253-8866
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JEPPSON
Authorized Official First Name:
TAELOR
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE COORDINATOR
Authorized Official Telephone Number:
801-305-3460

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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