Provider Demographics
NPI:1972264398
Name:OLIVE BRANCH DENTAL-2 LLC
Entity type:Organization
Organization Name:OLIVE BRANCH DENTAL-2 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DURSHANAPALI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-303-5955
Mailing Address - Street 1:2459 W JONATHAN MOORE PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-9206
Mailing Address - Country:US
Mailing Address - Phone:812-516-5777
Mailing Address - Fax:812-531-1177
Practice Address - Street 1:2459 W JONATHAN MOORE PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-9206
Practice Address - Country:US
Practice Address - Phone:812-516-5777
Practice Address - Fax:812-531-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty