Provider Demographics
NPI:1720642218
Name:ST. GEORGE PDC PLLC
Entity type:Organization
Organization Name:ST. GEORGE PDC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-628-8885
Mailing Address - Street 1:PO BOX 970895
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:801-350-3460
Mailing Address - Fax:801-335-6551
Practice Address - Street 1:1150 S BLUFF ST STE 1
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5236
Practice Address - Country:US
Practice Address - Phone:435-628-8885
Practice Address - Fax:435-656-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty