Provider Demographics
NPI:1831777127
Name:IVORY BLISS PC
Entity type:Organization
Organization Name:IVORY BLISS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:
Authorized Official - First Name:ANURADHA
Authorized Official - Middle Name:
Authorized Official - Last Name:VADDINENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-663-0076
Mailing Address - Street 1:6305 PRECINCT LINE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-4827
Mailing Address - Country:US
Mailing Address - Phone:817-663-0076
Mailing Address - Fax:
Practice Address - Street 1:6305 PRECINCT LINE RD STE 400
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-4827
Practice Address - Country:US
Practice Address - Phone:817-663-0076
Practice Address - Fax:817-663-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental