Healthcare Provider Details

I. General information

NPI: 1285212589
Provider Name (Legal Business Name): OTR DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1953 WEST CALIFORNIA AVE
SALT LAKE CITY UTAH
84104
UM

IV. Provider business mailing address

PO BOX 271069
SALT LAKE CITY UT
84127-1069
US

V. Phone/Fax

Practice location:
  • Phone: 801-886-9341
  • Fax: 801-886-1786
Mailing address:
  • Phone: 801-886-9341
  • Fax: 801-886-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: PROF. VANESSA N TOVAR
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-886-9341