Healthcare Provider Details

I. General information

NPI: 1023653052
Provider Name (Legal Business Name): EKATERINA A FEDOSEEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7011 LINDA VISTA RD
SAN DIEGO CA
92111-6307
US

IV. Provider business mailing address

7011 LINDA VISTA RD
SAN DIEGO CA
92111-6307
US

V. Phone/Fax

Practice location:
  • Phone: 858-810-8729
  • Fax:
Mailing address:
  • Phone: 858-810-8729
  • Fax: 858-987-5823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: