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General NPI Number Information
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NPI Number | 1265571426
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Entity Type | Organization
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Legal Business Name | NICHOLAS J FEDORKA DMD PC
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Dates
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Enumeration Date | 02/05/2007
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Last Update Date | 10/02/2007
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Provider Practice Location Address
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Address Line | 505 POPLAR STREET
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City | MEADVILLE
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State | PA
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Zip | 16335
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Country | US
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Telephone | 814-333-4454
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Fax | 814-336-3357
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Provider Business Mailing Address
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Address Line | 505 POPLAR STREET
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City | MEADVILLE
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State | PA
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Zip | 16335
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Country | US
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Telephone | 814-333-4454
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Fax | 814-336-3357
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Authorized Official
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Title or Position | OWNER ORAL & MAXILLOFACIAL SURGEON
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Name | DR. NICHOLAS JEROME FEDORKA
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Credential | DMD
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Telephone | 814-336-3357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number | DS023205L
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License Number State | PA
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