PDC Provo LLC

Primary specialty

DentistTaxonomy code 122300000X

License

6026130 Issued in UT

Legal business name

PDC PROVO LLC

Practice address

2520 N Univ Ave
Suite 101
Provo, UT 84604

Phone

(801) 426-6255

Fax

(801) 224-2966

NPI assigned

Jan 8, 2007

Last updated

Jan 4, 2013By the provider in NPPES

Organization subpart

Yes

Parent organization

PLATINUM DENTAL GROUP LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Amber Johnson

Title

Office Manager

Phone

(801) 426-6255

Specialties & licenses 2

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168214400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1357257600000",
    "number": "1396893012",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2520 N UNIV AVE",
            "address_2": "SUITE 101",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "84604",
            "telephone_number": "801-426-6255",
            "fax_number": "801-224-2966"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2520 N UNIV AVE",
            "address_2": "SUITE 101",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "84604",
            "telephone_number": "801-426-6255",
            "fax_number": "801-224-2966"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PDC PROVO LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PLATINUM DENTAL GROUP LLC",
        "enumeration_date": "2007-01-08",
        "last_updated": "2013-01-04",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "AMBER",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "801-426-6255"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "UT",
            "license": "6026130",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "UT",
            "license": "3192",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "529113131001",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Katelynn Laurel Payne
• Sara Payne
• Sydnee Payne
• Thomas Payne, LCSW
• Wendy Jade Payne, MD
• Deanna Lynn Peabody, OT
• John R Peabody, PT
• Laurel Ann Peacock
• Daniel Joel Pead, RPH
• Peak Balance Mental Health and Wellness

• Dentist in Provo, UT
• Providers in Provo, UT by specialty
• Dentist in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 4, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.