Provider Demographics
NPI:1417908179
Name:IDDINGS, JOHN RANDOLPH (DDS0)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDOLPH
Last Name:IDDINGS
Suffix:
Gender:M
Credentials:DDS0
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 CRAB ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ARM
Mailing Address - State:MD
Mailing Address - Zip Code:21057-9752
Mailing Address - Country:US
Mailing Address - Phone:410-605-7057
Mailing Address - Fax:410-605-7819
Practice Address - Street 1:VAMC 10 NORTH GREENE ST
Practice Address - Street 2:DENTAL SERVICE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7057
Practice Address - Fax:410-605-7819
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD41711223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics