Healthcare Provider Details

I. General information

NPI: 1184065294
Provider Name (Legal Business Name): CLEO BIANCA VIDICAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLIO VIDICAN DDS

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-5564
US

IV. Provider business mailing address

PO BOX 100414
GAINESVILLE FL
32610-0414
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-6695
  • Fax: 352-294-5310
Mailing address:
  • Phone: 352-273-6695
  • Fax: 352-294-5310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number25780
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberDN23503
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberD13261
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number11848
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number2901600790
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number25780
License Number StateMT
# 7
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11848
License Number StateTN
# 8
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13261
License Number StateMN
# 9
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600790
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: