Provider Demographics
NPI:1992189963
Name:NOVA DENTAL GAITHERSBURG LLC
Entity Type:Organization
Organization Name:NOVA DENTAL GAITHERSBURG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:240-477-8006
Mailing Address - Street 1:806 W DIAMOND AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1415
Mailing Address - Country:US
Mailing Address - Phone:240-477-8006
Mailing Address - Fax:240-477-7944
Practice Address - Street 1:806 W DIAMOND AVE STE 300
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1415
Practice Address - Country:US
Practice Address - Phone:240-477-8006
Practice Address - Fax:240-477-7944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-19
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11190261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental