Provider Demographics
NPI:1780466011
Name:VIDALES DENTAL CORP
Entity type:Organization
Organization Name:VIDALES DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATEO
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDALES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:863-225-5600
Mailing Address - Street 1:6958 SHIMMERING DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3331
Mailing Address - Country:US
Mailing Address - Phone:813-818-8056
Mailing Address - Fax:
Practice Address - Street 1:6958 SHIMMERING DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3331
Practice Address - Country:US
Practice Address - Phone:813-818-8056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty