# FAMILIA DENTAL TERRE HAUTE LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Vivid Smiles
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619433737
- **Authorized official:** MR. BRANDON ALEXANDER TAYLOR CPCS (CREDENTIALING&PAYERRELATIONSMANAGER)
- **Authorized official phone:** (847) 453-7396

## Contact information

- **Practice address:** 2512 WABASH AVE, TERRE HAUTE, IN 47803-1506
- **Practice address phone:** (888) 988-4066
- **Mailing address:** 2050 E ALGONQUIN RD STE 610, SCHAUMBURG, IL 60173-4166
- **Mailing address phone:** (888) 988-4066
- **Mailing address fax:** (847) 496-4850

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | — | — |
| 261QD0000X | Dental Clinic/Center | — | — | Yes |

## Other

- **Enumeration date:** 02/13/2019
- **Last updated:** 10/21/2021