Healthcare Provider Details

I. General information

NPI: 1144850926
Provider Name (Legal Business Name): FIDANOSKI DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 WHITLOCK AVE NW
MARIETTA GA
30064-1933
US

IV. Provider business mailing address

1150 WHITLOCK AVE NW
MARIETTA GA
30064-1933
US

V. Phone/Fax

Practice location:
  • Phone: 770-338-3389
  • Fax:
Mailing address:
  • Phone: 770-338-3389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BOBAN FIDANOSKI
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 770-338-3389