Provider Demographics
NPI:1093222598
Name:OLLOM DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:OLLOM DENTAL GROUP, LLC
Other - Org Name:PURE SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:OLLOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-572-5600
Mailing Address - Street 1:7477 RATCHFORD CT
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 S SUNBURY RD STE 201
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-9444
Practice Address - Country:US
Practice Address - Phone:614-392-8090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-05
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty