MEDICARE: DANIELA VIVALDI DDS

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	1223X2210X	Orofacial Pain Dentistry	0225	NC
2	390200000X	Student in an Organized Health Care Education/Training Program	151115	NC
3	1223X2210X	Orofacial Pain Dentistry	12546	NC

General Provider Information

NPI Number	:	1558814491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELA VIVALDI DDS

Provider Business Mailing Address
First Line	:	10207 CERNY ST STE 114
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-4880
Country	:	US
Telephone Number	:	919-660-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	10207 CERNY ST STE 114
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-4880
Country	:	US
Telephone Number	:	919-660-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/19/2022

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