Provider Demographics
NPI:1316633001
Name:BELLA VIDA DENTAL LLC
Entity type:Organization
Organization Name:BELLA VIDA DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:DENTAL CONSULTANT
Authorized Official - Phone:480-370-3365
Mailing Address - Street 1:PO BOX 77360
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85703-7360
Mailing Address - Country:US
Mailing Address - Phone:480-370-3365
Mailing Address - Fax:
Practice Address - Street 1:4625 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-1639
Practice Address - Country:US
Practice Address - Phone:480-370-3365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty