MEDICARE: VIBRANT ORTHODONTICS, PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1144986316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIBRANT ORTHODONTICS, PLLC

Provider Business Mailing Address
First Line	:	1350 THOMASWOOD DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-7914
Country	:	US
Telephone Number	:	850-385-8101
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 THOMASWOOD DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-7914
Country	:	US
Telephone Number	:	850-385-8101
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MARYAM REZAIE
Credential	:	DMD
Telephone Number	:	850-385-8101

Provider Enumeration Date	:	11/12/2021
Last Update Date	:	11/12/2021

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