Provider Demographics
NPI:1053852202
Name:OPTIM DENTAL -1 LLC
Entity Type:Organization
Organization Name:OPTIM DENTAL -1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DURSHANAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-303-5955
Mailing Address - Street 1:3353 S US HIGHWAY 41 UNIT 3369
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3727
Mailing Address - Country:US
Mailing Address - Phone:812-777-8777
Mailing Address - Fax:
Practice Address - Street 1:3353 S US HIGHWAY 41 UNIT 3369
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3727
Practice Address - Country:US
Practice Address - Phone:812-777-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty