Healthcare Provider Details

I. General information

NPI: 1114344843
Provider Name (Legal Business Name): OLYMPUS DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19231 MONTGOMERY VILLAGE AVE SUITE D12
GAITHERSBURG MD
20886-5023
US

IV. Provider business mailing address

19231 MONTGOMERY VILLAGE AVE SUITE D12
GAITHERSBURG MD
20886-5023
US

V. Phone/Fax

Practice location:
  • Phone: 240-780-7002
  • Fax: 240-780-7022
Mailing address:
  • Phone: 240-780-7002
  • Fax: 240-780-7022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. NAVEEN KWATRA
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 240-780-7002