Provider Demographics
NPI:1710423280
Name:VIVA DENTAL
Entity Type:Organization
Organization Name:VIVA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:CABBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-522-0908
Mailing Address - Street 1:3837 N HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2742
Mailing Address - Country:US
Mailing Address - Phone:317-522-0908
Mailing Address - Fax:317-282-0682
Practice Address - Street 1:3837 N HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254
Practice Address - Country:US
Practice Address - Phone:317-522-0908
Practice Address - Fax:317-282-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010607A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental