Basic Information
| Provider Information | |||||||||
| NPI: | 1417503673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIEDORCZUK | ||||||||
| FirstName: | KINGA | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3201 S ST APT 279 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102993468 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8204 DELTA SHORES CIR S STE 140 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958329111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162779069 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2019 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 104301 | CA | N | Dental Providers | Dentist | 1223G0001X | 104301 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.