=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114344843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLYMPUS DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2014
-----------------------------------------------------
Last Update Date | 10/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19231 MONTGOMERY VILLAGE AVE SUITE D12
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20886-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-780-7002
-----------------------------------------------------
Fax | 240-780-7022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19231 MONTGOMERY VILLAGE AVE SUITE D12
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20886-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-780-7002
-----------------------------------------------------
Fax | 240-780-7022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. NAVEEN KWATRA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 240-780-7002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------