Provider Demographics
NPI:1285212589
Name:OTR DENTAL PLLC
Entity type:Organization
Organization Name:OTR DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:PROF
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:N
Authorized Official - Last Name:TOVAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-886-9341
Mailing Address - Street 1:PO BOX 271069
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-1069
Mailing Address - Country:US
Mailing Address - Phone:801-886-9341
Mailing Address - Fax:801-886-1786
Practice Address - Street 1:1953 WEST CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UTAH
Practice Address - Zip Code:84104
Practice Address - Country:UM
Practice Address - Phone:801-886-9341
Practice Address - Fax:801-886-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1962671495OtherNPI