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General NPI Number Information
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NPI Number | 1992189963
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Entity Type | Organization
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Legal Business Name | NOVA DENTAL GAITHERSBURG LLC
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Dates
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Enumeration Date | 07/19/2015
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Last Update Date | 07/19/2015
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Provider Practice Location Address
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Address Line | 806 W DIAMOND AVE STE 300
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City | GAITHERSBURG
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State | MD
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Zip | 20878-1415
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Country | US
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Telephone | 240-477-8006
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Fax | 240-477-7944
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Provider Business Mailing Address
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Address Line | 806 W DIAMOND AVE STE 300
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City | GAITHERSBURG
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State | MD
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Zip | 20878-1415
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Country | US
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Telephone | 240-477-8006
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Fax | 240-477-7944
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | DR. DMITRY NOVA
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Credential | DDS
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Telephone | 240-477-8006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 11190
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License Number State | MD
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