Provider Demographics
NPI:1316058241
Name:FEDAK, KEVIN DEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DEAN
Last Name:FEDAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5330 CORPORATE CENTER LOOP SE STE B
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5558
Mailing Address - Country:US
Mailing Address - Phone:360-456-5151
Mailing Address - Fax:360-456-0525
Practice Address - Street 1:5330 CORPORATE CENTER LOOP SE STE B
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5558
Practice Address - Country:US
Practice Address - Phone:360-456-5151
Practice Address - Fax:360-456-0525
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA75141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice