MEDICARE: VIDAMAX DENTAL GROUP CORP

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1417604166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIDAMAX DENTAL GROUP CORP

Provider Business Mailing Address
First Line	:	2040 WASHINGTON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6930
Country	:	US
Telephone Number	:	754-348-5001
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 WASHINGTON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-6930
Country	:	US
Telephone Number	:	754-348-5001
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RAISA CORTES FONTANET
Credential	:
Telephone Number	:	786-715-5571

Provider Enumeration Date	:	03/02/2022
Last Update Date	:	03/02/2022

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Directions to “VIDAMAX DENTAL GROUP CORP ” Practice Location

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