MEDICARE: OVER THE ROAD DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	143681-9922	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912014234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OVER THE ROAD DENTAL

Provider Business Mailing Address
First Line	:	PO BOX 271069
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-1069
Country	:	US
Telephone Number	:	801-886-9341
Fax Number	:	801-886-1786

Provider Business Practice Location Address
First Line	:	1953 W. CALIFORNIA AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104
Country	:	US
Telephone Number	:	801-886-9341
Fax Number	:	801-886-1786

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ANGIE BREEZE
Credential	:
Telephone Number	:	801-886-9341

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	08/22/2020

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Directions to “OVER THE ROAD DENTAL ” Practice Location

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