Provider Demographics
NPI:1851175780
Name:VIDENTA, LLC
Entity Type:Organization
Organization Name:VIDENTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-577-6367
Mailing Address - Street 1:907 N ANKENY BLVD
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4002
Mailing Address - Country:US
Mailing Address - Phone:515-964-1490
Mailing Address - Fax:
Practice Address - Street 1:907 N ANKENY BLVD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4002
Practice Address - Country:US
Practice Address - Phone:515-964-1490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty