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Provider Information for 1053852202

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OPTIM DENTAL -1 LLC

Organization Subpart: NO

Organization NPI: 1053852202

Calendar   Last Updated:  2017-03-20
  Certification Date: 

Details

Name Value
NPI 1053852202
Enumeration Date 2017-03-20
NPI Type 2- Organization
Status Active
Authorized Official Information Name: SRINIVAS DURSHANAPALLI DDS
Title: PRESIDENT
Phone: 217-303-5955
Mailing Address 3353 S US HIGHWAY 41 UNIT 3369
TERRE HAUTE, IN 47802-3727
United States

Phone: 812-777-8777 | Fax:
View Map External Link
Primary Practice Address 3353 S US HIGHWAY 41 UNIT 3369
TERRE HAUTE, IN 47802-3727
United States

Phone: 812-777-8777 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Taxonomy
Primary Taxonomy Selected Taxonomy State License Number
Yes 193400000X SINGLE SPECIALTY GROUP
1223G0001X - Dentist General Practice