Provider Demographics
NPI:1114344843
Name:OLYMPUS DENTAL LLC
Entity Type:Organization
Organization Name:OLYMPUS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KWATRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-780-7002
Mailing Address - Street 1:19231 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:SUITE D12
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886-5023
Mailing Address - Country:US
Mailing Address - Phone:240-780-7002
Mailing Address - Fax:240-780-7022
Practice Address - Street 1:19231 MONTGOMERY VILLAGE AVE
Practice Address - Street 2:SUITE D12
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20886-5023
Practice Address - Country:US
Practice Address - Phone:240-780-7002
Practice Address - Fax:240-780-7022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD013988200Medicaid