Provider Demographics
NPI:1528581873
Name:OMELIANCIC, VITALII (DMD)
Entity Type:Individual
Prefix:
First Name:VITALII
Middle Name:
Last Name:OMELIANCIC
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6407
Mailing Address - Country:US
Mailing Address - Phone:215-919-1658
Mailing Address - Fax:
Practice Address - Street 1:3227 W BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611
Practice Address - Country:US
Practice Address - Phone:864-295-8888
Practice Address - Fax:864-295-1241
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8989122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist