Healthcare Provider Details

I. General information

NPI: 1417947789
Provider Name (Legal Business Name): JAY FEDOROWICZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
FAIRFIELD CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR
FAIRFIELD CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 74-237-1037
  • Fax:
Mailing address:
  • Phone: 707-423-7103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9711
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: