South Provo PDC PLLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

Legal business name

SOUTH PROVO PDC PLLC

Practice address

2211 E Valley Vista Way
Provo, UT 84606-5636

Phone

(385) 412-6964

Fax

(385) 248-5034

NPI assigned

Sep 14, 2023

Last updated

Nov 8, 2023By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Vivian Betancourt

Title

Credentialing Specialist

Phone

(801) 305-3465

Specialties & licenses 1

Addresses

Locations

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

{
    "created_epoch": "1694649600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1699401600000",
    "number": "1538946207",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 970185",
            "city": "OREM",
            "state": "UT",
            "postal_code": "840970185",
            "telephone_number": "801-691-1701",
            "fax_number": "801-355-6551"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2211 E VALLEY VISTA WAY",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846065636",
            "telephone_number": "385-412-6964",
            "fax_number": "385-248-5034"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH PROVO PDC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-09-14",
        "last_updated": "2023-11-08",
        "certification_date": "2023-11-08",
        "status": "A",
        "authorized_official_last_name": "BETANCOURT",
        "authorized_official_first_name": "VIVIAN",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "801-305-3465"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Weston Mark Sorenson, DC
• Jackie Soto, PT, DPT
• Marilyn Tucker Soto, MSWI
• Patricia Sotolongo, PSYD
• Sound Sleep Medical LLC (Sound Sleep Medical)
• Courtenay Anne South
• Samuel Lynn Southam, MD
• Cassandra Southwick
• Jeremiah Southworth
• Cedric W. Spak, MD

• Dental Clinic/Center in Provo, UT
• Providers in Provo, UT by specialty
• Dental Clinic/Center in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2023; 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.