Provider Demographics
NPI:1053904409
Name:OLIVE BRANCH DENTAL LLC
Entity type:Organization
Organization Name:OLIVE BRANCH DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DURSHANAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:217-303-5955
Mailing Address - Street 1:2826 S STATE ROAD 135 STE C
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2826 S STATE ROAD 135 STE C
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9603
Practice Address - Country:US
Practice Address - Phone:317-743-7777
Practice Address - Fax:317-854-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-17
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty