Provider Demographics
NPI:1023615556
Name:VIDA ORTHODONTICS
Entity type:Organization
Organization Name:VIDA ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOVERSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:701-426-0938
Mailing Address - Street 1:4519 W 37TH PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-2395
Mailing Address - Country:US
Mailing Address - Phone:701-426-0938
Mailing Address - Fax:
Practice Address - Street 1:19551 HESS RD UNIT 110
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-3446
Practice Address - Country:US
Practice Address - Phone:701-426-0938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental