Provider Demographics
NPI:1144986316
Name:VIBRANT ORTHODONTICS, PLLC
Entity type:Organization
Organization Name:VIBRANT ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REZAIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-385-8101
Mailing Address - Street 1:1350 THOMASWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7914
Mailing Address - Country:US
Mailing Address - Phone:850-385-8101
Mailing Address - Fax:
Practice Address - Street 1:1350 THOMASWOOD DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7914
Practice Address - Country:US
Practice Address - Phone:850-385-8101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty