Provider Demographics
NPI:1508210857
Name:NOVA DENTAL PC
Entity Type:Organization
Organization Name:NOVA DENTAL PC
Other - Org Name:PARK HEIGHTS DENTAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
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:443-465-2047
Mailing Address - Street 1:4 PARK CENTER CT
Mailing Address - Street 2:SUITE # 201
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5611
Mailing Address - Country:US
Mailing Address - Phone:410-363-6868
Mailing Address - Fax:410-363-6944
Practice Address - Street 1:4 PARK CENTER CT
Practice Address - Street 2:SUITE # 201
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5611
Practice Address - Country:US
Practice Address - Phone:410-363-6868
Practice Address - Fax:410-363-6944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16079122300000X
MD11190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty