Healthcare Provider Details

I. General information

NPI: 1396684429
Provider Name (Legal Business Name): VIDA DENTAL AND SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 BEACON ST STE 514
BROOKLINE MA
02446-5622
US

IV. Provider business mailing address

1051 BEACON ST STE 514
BROOKLINE MA
02446-5622
US

V. Phone/Fax

Practice location:
  • Phone: 617-383-5275
  • Fax:
Mailing address:
  • Phone: 617-383-5275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KAMAND SHAIBANI
Title or Position: OWNER
Credential: DMD
Phone: 617-501-8885