Provider Demographics
NPI:1790354546
Name:SORRELL, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:SORRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 N 1200 E
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 N 1200 E
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2446
Practice Address - Country:US
Practice Address - Phone:502-254-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12340917-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist