Provider Demographics
NPI:1912014234
Name:OVER THE ROAD DENTAL
Entity Type:Organization
Organization Name:OVER THE ROAD DENTAL
Other - Org Name:MICHEL B. HAYNIE
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-886-9341
Mailing Address - Street 1:PO BOX 271069
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-1069
Mailing Address - Country:US
Mailing Address - Phone:801-886-9341
Mailing Address - Fax:801-886-1786
Practice Address - Street 1:1953 W. CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104
Practice Address - Country:US
Practice Address - Phone:801-886-9341
Practice Address - Fax:801-886-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT143681-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT545764459023Medicaid