Provider Demographics
NPI:1407613342
Name:UT OMS SPECIALTY DENTAL SERVICES PLLC
Entity Type:Organization
Organization Name:UT OMS SPECIALTY DENTAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CRED AND PR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:E
Authorized Official - Last Name:VIAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-638-0303
Mailing Address - Street 1:1610 54TH AVE N STE 205
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1442
Mailing Address - Country:US
Mailing Address - Phone:615-678-0759
Mailing Address - Fax:
Practice Address - Street 1:4046 S HIGHLAND DR STE 112
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1687
Practice Address - Country:US
Practice Address - Phone:801-273-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UT OMS SPECIALTY DENTAL SERVICES PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty