Provider Demographics
NPI:1366452526
Name:VIDIC, JOHNNY ROMAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:ROMAN
Last Name:VIDIC
Suffix:
Gender:M
Credentials:DDS
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Other - Credentials:
Mailing Address - Street 1:351 WEST 6TH STREET, BLDG 440
Mailing Address - Street 2:USA DENTAC - ATTN: CREDENTIALS
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-4704
Mailing Address - Country:US
Mailing Address - Phone:912-767-6735
Mailing Address - Fax:912-870-6735
Practice Address - Street 1:351 WEST 6TH STREET, BLDG 440
Practice Address - Street 2:USA DENTAC - ATTN: CREDENTIALS
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-4704
Practice Address - Country:US
Practice Address - Phone:912-767-6735
Practice Address - Fax:912-870-6735
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD137761223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics