Provider Demographics
NPI:1013069848
Name:ORAL & MAXILLOFACIAL IMAGING CENTER, INC.
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL IMAGING CENTER, INC.
Other - Org Name:OMIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DRT
Authorized Official - Phone:801-942-5003
Mailing Address - Street 1:7001 S 900 E
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1718
Mailing Address - Country:US
Mailing Address - Phone:801-255-8899
Mailing Address - Fax:
Practice Address - Street 1:7001 S 900 E
Practice Address - Street 2:SUITE 310
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1718
Practice Address - Country:US
Practice Address - Phone:801-255-8899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT39396292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory