Provider Demographics
NPI:1417604166
Name:VIDAMAX DENTAL GROUP CORP
Entity Type:Organization
Organization Name:VIDAMAX DENTAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORTES FONTANET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-715-5571
Mailing Address - Street 1:2040 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-6930
Mailing Address - Country:US
Mailing Address - Phone:754-348-5001
Mailing Address - Fax:
Practice Address - Street 1:2040 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6930
Practice Address - Country:US
Practice Address - Phone:754-348-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental