Provider Demographics
NPI:1467605196
Name:VIDENA, DEXTER PAMATIGAN (PT)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:PAMATIGAN
Last Name:VIDENA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 KAISER DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4555
Mailing Address - Country:US
Mailing Address - Phone:410-608-2912
Mailing Address - Fax:
Practice Address - Street 1:3290 N RIDGE RD
Practice Address - Street 2:SUITE 290
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3655
Practice Address - Country:US
Practice Address - Phone:410-750-9006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-26
Last Update Date:2008-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist