Provider Demographics
NPI:1114686318
Name:VIBRANT DENTAL LLC
Entity type:Organization
Organization Name:VIBRANT DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALERI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIDO-WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-427-5562
Mailing Address - Street 1:150 PROFESSIONAL CT STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5153
Mailing Address - Country:US
Mailing Address - Phone:765-448-4242
Mailing Address - Fax:
Practice Address - Street 1:150 PROFESSIONAL CT STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5153
Practice Address - Country:US
Practice Address - Phone:765-448-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty