Provider Demographics
NPI:1275774234
Name:KENTLANDS OPTOMETRY, LLC
Entity Type:Organization
Organization Name:KENTLANDS OPTOMETRY, LLC
Other - Org Name:MY EYE DR.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-658-4019
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:KENTLANDS PLACE SHOPPING CENTER
Practice Address - Street 2:80 MARKET STREET
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878
Practice Address - Country:US
Practice Address - Phone:301-990-1122
Practice Address - Fax:703-991-0514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-20
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDTA1970OtherSTATE LICENSE