Basic Information
| Provider Information | |||||||||
| NPI: | 1467605196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDENA | ||||||||
| FirstName: | DEXTER | ||||||||
| MiddleName: | PAMATIGAN | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3264 KAISER DR | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210434555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106082912 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3290 N RIDGE RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210433655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107509006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2008 | ||||||||
| LastUpdateDate: | 10/26/2008 | ||||||||
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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 | 225100000X | 22673 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.