MEDICARE: VIVID DENTAL LLC

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	:	1538844337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIVID DENTAL LLC

Provider Business Mailing Address
First Line	:	9310 W SAHARA AVE STE 2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5399
Country	:	US
Telephone Number	:	702-625-4225
Fax Number	:

Provider Business Practice Location Address
First Line	:	9310 W SAHARA AVE STE 2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5399
Country	:	US
Telephone Number	:	702-625-4225
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JINBO CHUNG
Credential	:	DMD
Telephone Number	:	213-999-1731

Provider Enumeration Date	:	06/19/2023
Last Update Date	:	06/19/2023

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Directions to “VIVID DENTAL LLC ” Practice Location

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