Provider Demographics
NPI:1477953677
Name:IDNANI, VIBHOR (DMD)
Entity Type:Individual
Prefix:
First Name:VIBHOR
Middle Name:
Last Name:IDNANI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16235 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-2736
Mailing Address - Country:US
Mailing Address - Phone:561-637-4443
Mailing Address - Fax:
Practice Address - Street 1:16235 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-2736
Practice Address - Country:US
Practice Address - Phone:561-637-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN209611223G0001X
MADN1856693122300000X
IADDS-092401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1598152019Medicaid