Provider Demographics
NPI:1588116347
Name:VIDA DENTAL SPA
Entity type:Organization
Organization Name:VIDA DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:IOANNOU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-475-6789
Mailing Address - Street 1:1101 154TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1954
Mailing Address - Country:US
Mailing Address - Phone:718-475-6789
Mailing Address - Fax:718-504-7500
Practice Address - Street 1:1101 154TH ST
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1954
Practice Address - Country:US
Practice Address - Phone:718-475-6789
Practice Address - Fax:718-504-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050794122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty