Provider Demographics
NPI:1326442286
Name:OPAL RIDGEDENTAL LLC
Entity Type:Organization
Organization Name:OPAL RIDGEDENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENJU
Authorized Official - Middle Name:ALEX
Authorized Official - Last Name:THACKENKARY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-788-8224
Mailing Address - Street 1:1700 KINGFISHER DR
Mailing Address - Street 2:SUITE 11
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701
Mailing Address - Country:US
Mailing Address - Phone:301-788-8224
Mailing Address - Fax:
Practice Address - Street 1:1700 KINGFISHER DR
Practice Address - Street 2:SUITE 11
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4775
Practice Address - Country:US
Practice Address - Phone:301-788-8224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD154341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty