Provider Demographics
NPI:1396833174
Name:OVERLAND OPTICAL, INC
Entity Type:Organization
Organization Name:OVERLAND OPTICAL, INC
Other - Org Name:OVERLAND OPTICAL FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:DENTSBIER
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:314-401-5570
Mailing Address - Street 1:1529 S OLD HIGHWAY 94 STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-3707
Mailing Address - Country:US
Mailing Address - Phone:314-423-3874
Mailing Address - Fax:888-423-0074
Practice Address - Street 1:1529 S OLD HIGHWAY 94 STE 120
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3707
Practice Address - Country:US
Practice Address - Phone:636-949-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO036582156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000007928Medicare PIN
MO0381830002Medicare NSC