Healthcare Provider Details

I. General information

NPI: 1811372154
Provider Name (Legal Business Name): VIVIANA PATRICIA MORA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 NW 9TH AVE
MULBERRY FL
33860-2922
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 863-291-5110
  • Fax: 863-291-5128
Mailing address:
  • Phone: 863-291-5110
  • Fax: 863-291-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN21456
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: