Basic Information
| Provider Information | |||||||||
| NPI: | 1528581873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OMELIANCIC | ||||||||
| FirstName: | VITALII | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE STE 150 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159191658 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3227 W BLUE RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642958888 | ||||||||
| FaxNumber: | 8642951241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8989 | SC | N | Dental Providers | Dentist | 1223G0001X | 8989 | SC | Y | Dental Providers | Dentist | General Practice |
No ID Information.