Provider Demographics
NPI:1023390473
Name:FEDERSPIEL, JON (DDS)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:FEDERSPIEL
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 1:319TH MEDICAL GROUP
Mailing Address - Street 2:1599 J STREET
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319TH MEDICAL GROUP
Practice Address - Street 2:1599 J STREET
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58205
Practice Address - Country:US
Practice Address - Phone:317-361-0581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011671A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice