Healthcare Provider Details

I. General information

NPI: 1487135570
Provider Name (Legal Business Name): VI COSMETIC DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9149 ESTATE THOMAS STE 201
ST THOMAS VI
00802-3132
US

IV. Provider business mailing address

9149 ESTATE THOMAS STE 201
ST THOMAS VI
00802-3132
US

V. Phone/Fax

Practice location:
  • Phone: 340-777-5950
  • Fax: 407-386-7222
Mailing address:
  • Phone: 340-777-5950
  • Fax: 407-386-7222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MISS MARISA MADURO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 340-777-5950