Provider Demographics
NPI:1326521139
Name:VITAL DENTAL
Entity Type:Organization
Organization Name:VITAL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZAHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGHERI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-535-1068
Mailing Address - Street 1:180 NASSAU ST APT 8A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-2198
Mailing Address - Country:US
Mailing Address - Phone:781-535-1068
Mailing Address - Fax:
Practice Address - Street 1:30 E 40TH ST RM 201
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1221
Practice Address - Country:US
Practice Address - Phone:781-535-1068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122400000XDental ProvidersDenturistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No125J00000XDental ProvidersDental TherapistGroup - Multi-Specialty
No125K00000XDental ProvidersAdvanced Practice Dental TherapistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
No126900000XDental ProvidersDental Laboratory TechnicianGroup - Multi-Specialty