Provider Demographics
NPI:1306291422
Name:PDC RIVERTON LLC
Entity type:Organization
Organization Name:PDC RIVERTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAELOR
Authorized Official - Middle Name:
Authorized Official - Last Name:JEPPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-305-3460
Mailing Address - Street 1:2476 N UNIVERSITY PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3869
Mailing Address - Country:US
Mailing Address - Phone:801-305-3460
Mailing Address - Fax:801-692-9083
Practice Address - Street 1:2364 W 12600 S
Practice Address - Street 2:STE 1A
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7109
Practice Address - Country:US
Practice Address - Phone:801-253-8866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty