Provider Demographics
NPI:1477226892
Name:VIVID SMILES
Entity Type:Organization
Organization Name:VIVID SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIVONI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-333-6077
Mailing Address - Street 1:7011 BACKLICK CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-3903
Mailing Address - Country:US
Mailing Address - Phone:703-333-6077
Mailing Address - Fax:
Practice Address - Street 1:7011 BACKLICK CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3903
Practice Address - Country:US
Practice Address - Phone:703-333-6077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty