Provider Demographics
NPI:1942997176
Name:ATENCIO, JOHNNY NICO (BS)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:NICO
Last Name:ATENCIO
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TUSKEGEE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOVER AFB
Mailing Address - State:DE
Mailing Address - Zip Code:19902-5003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902-5003
Practice Address - Country:US
Practice Address - Phone:302-730-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CODEN.00205615122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer