Basic Information
Provider Information | |||||||||
NPI: | 1275774234 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENTLANDS OPTOMETRY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MY EYE DR. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8614 WESTWOOD CENTER DR FL 9 | ||||||||
Address2: |   | ||||||||
City: | VIENNA | ||||||||
State: | VA | ||||||||
PostalCode: | 221822442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038478899 | ||||||||
FaxNumber: | 5712236780 | ||||||||
Practice Location | |||||||||
Address1: | KENTLANDS PLACE SHOPPING CENTER | ||||||||
Address2: | 80 MARKET STREET | ||||||||
City: | GAITHERSBURG | ||||||||
State: | MD | ||||||||
PostalCode: | 20878 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3019901122 | ||||||||
FaxNumber: | 7039910514 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2009 | ||||||||
LastUpdateDate: | 05/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOWNES | ||||||||
AuthorizedOfficialFirstName: | SUE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 7038478899 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA1970 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | TA1970 | 01 | MD | STATE LICENSE | OTHER |