Provider Demographics
NPI:1669994109
Name:FIDANOSKI, BOBAN (DMD)
Entity type:Individual
Prefix:DR
First Name:BOBAN
Middle Name:
Last Name:FIDANOSKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 WHITLOCK AVE NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1933
Mailing Address - Country:US
Mailing Address - Phone:770-338-3389
Mailing Address - Fax:
Practice Address - Street 1:1150 WHITLOCK AVE NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1933
Practice Address - Country:US
Practice Address - Phone:770-338-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-15
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0153831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice