Provider Demographics
NPI:1144850926
Name:FIDANOSKI DENTISTRY, LLC
Entity type:Organization
Organization Name:FIDANOSKI DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FIDANOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-338-3389
Mailing Address - Street 1:1150 WHITLOCK AVE NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1933
Mailing Address - Country:US
Mailing Address - Phone:770-338-3389
Mailing Address - Fax:
Practice Address - Street 1:1150 WHITLOCK AVE NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1933
Practice Address - Country:US
Practice Address - Phone:770-338-3389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental