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General NPI Number Information
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NPI Number | 1487192340
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Entity Type | Organization
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Legal Business Name | VIDA DENTAL SPA INC
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Dates
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Enumeration Date | 02/10/2017
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Last Update Date | 02/10/2017
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Provider Practice Location Address
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Address Line | 1101 154TH ST
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City | WHITESTONE
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State | NY
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Zip | 11357-1954
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Country | US
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Telephone | 718-559-6090
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Fax | 718-504-7500
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Provider Business Mailing Address
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Address Line | 1101 154TH ST
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City | WHITESTONE
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State | NY
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Zip | 11357-1954
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Country | US
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Telephone | 718-559-6090
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Fax | 718-504-7500
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARIA TERESA IOANNOU
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Credential | DDS
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Telephone | 917-842-9807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 050794
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License Number State | NY
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