MEDICARE: VIVI SPA DENTAL P.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	18603	FL

General Provider Information

NPI Number	:	1598197964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIVI SPA DENTAL P.A

Provider Business Mailing Address
First Line	:	10722 KETCHUM VALLEY DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33579-7185
Country	:	US
Telephone Number	:	813-671-0675
Fax Number	:

Provider Business Practice Location Address
First Line	:	10722 KETCHUM VALLEY DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33579-7185
Country	:	US
Telephone Number	:	813-671-0675
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	MRS. THUVAN T VO
Credential	:	D.M.D
Telephone Number	:	813-617-0675

Provider Enumeration Date	:	08/07/2013
Last Update Date	:	08/28/2013

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