Provider Demographics
NPI:1164621793
Name:ADVANCED DENTAL SPA
Entity Type:Organization
Organization Name:ADVANCED DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIANNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KHALIFE-YAZBECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:774-688-9226
Mailing Address - Street 1:140 DARTMOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740
Mailing Address - Country:US
Mailing Address - Phone:774-688-9226
Mailing Address - Fax:
Practice Address - Street 1:144 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-3101
Practice Address - Country:US
Practice Address - Phone:774-688-9226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty