Healthcare Provider Details

I. General information

NPI: 1396833174
Provider Name (Legal Business Name): OVERLAND OPTICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 S OLD HIGHWAY 94 STE 120
SAINT CHARLES MO
63303-3707
US

IV. Provider business mailing address

1529 S OLD HIGHWAY 94 STE 120
SAINT CHARLES MO
63303-3707
US

V. Phone/Fax

Practice location:
  • Phone: 636-949-2900
  • Fax:
Mailing address:
  • Phone: 314-423-3874
  • Fax: 888-423-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number036582
License Number StateMO

VIII. Authorized Official

Name: MR. RUSSELL G. DENTSBIER
Title or Position: OWNER/PRESIDENT
Credential: ABOC
Phone: 314-401-5570