Provider Demographics
NPI:1033117288
Name:FEDAK, DARYL ALVAN
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:ALVAN
Last Name:FEDAK
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:DARYL
Other - Middle Name:ALVAN
Other - Last Name:FEDAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5892 MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-5496
Mailing Address - Country:US
Mailing Address - Phone:541-741-7800
Mailing Address - Fax:541-741-7888
Practice Address - Street 1:5892 MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-5496
Practice Address - Country:US
Practice Address - Phone:541-741-7800
Practice Address - Fax:541-741-7888
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
7696119OtherAETNA
1407366OtherUNITED CONCORDIA