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NPI Code Detail

MEDICARE: OLIVE BRANCH DENTAL-1 LLC

MEDICARE: OLIVE BRANCH DENTAL-1 LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry

General Provider Information

NPI Number : 1356002778
Entity Type Code : Organization
Provider Name (Legal Business Name) : OLIVE BRANCH DENTAL-1 LLC
Provider Business Mailing Address
First Line : 5470 LAFAYETTE RD
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46254-1620
Country : US
Telephone Number : 317-643-7777
Fax Number : 317-933-8454
Provider Business Practice Location Address
First Line : 5470 LAFAYETTE RD
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46254-1620
Country : US
Telephone Number : 317-643-7777
Fax Number : 317-933-8454
Authorized Official
Title or Position : PRESIDENT
Name : DR. SRINIVAS DURSHANAPALLI
Credential : DDS
Telephone Number : 217-303-5955
Provider Enumeration Date : 01/07/2022
Last Update Date : 01/07/2022

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Directions to “OLIVE BRANCH DENTAL-1 LLC ” Practice Location

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