Provider Demographics
NPI:1205158524
Name:VIDEKA DENTAL PC
Entity type:Organization
Organization Name:VIDEKA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:VIDEKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-798-0444
Mailing Address - Street 1:1924 HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2239
Mailing Address - Country:US
Mailing Address - Phone:708-798-0444
Mailing Address - Fax:708-798-3358
Practice Address - Street 1:1924 HICKORY RD
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2239
Practice Address - Country:US
Practice Address - Phone:708-798-0444
Practice Address - Fax:708-798-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018734261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental