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Organization
SOUTH PROVO PDC PLLC
Active
Organization
SOUTH PROVO PDC PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VIVIAN BETANCOURT (CREDENTIALING SPECIALIST)
(801) 305-3465
Entity
Organization
Contact information
Practice address
2211 E VALLEY VISTA WAY, PROVO, UT 84606-5636
(385) 412-6964
(385) 248-5034
Mailing address
PO BOX 970185, OREM, UT 84097-0185
(801) 691-1701
(801) 355-6551
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Enumeration date
09/14/2023
Last updated
11/08/2023
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