Provider Demographics
NPI:1902381247
Name:VIDETICH, LAURA BREANNA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:BREANNA
Last Name:VIDETICH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5331 S 118TH CT APT 301
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3811
Mailing Address - Country:US
Mailing Address - Phone:402-201-3030
Mailing Address - Fax:
Practice Address - Street 1:5331 S 118TH CT APT 301
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3811
Practice Address - Country:US
Practice Address - Phone:402-201-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist