Basic Information
| Provider Information | |||||||||
| NPI: | 1366452526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIDIC | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | ROMAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 WEST 6TH STREET, BLDG 440 | ||||||||
| Address2: | USA DENTAC - ATTN: CREDENTIALS | ||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313144704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127676735 | ||||||||
| FaxNumber: | 9128706735 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 WEST 6TH STREET, BLDG 440 | ||||||||
| Address2: | USA DENTAC - ATTN: CREDENTIALS | ||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313144704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127676735 | ||||||||
| FaxNumber: | 9128706735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0700X | 13776 | MD | Y | Dental Providers | Dentist | Prosthodontics |
No ID Information.