Provider Demographics
NPI:1417503673
Name:FIEDORCZUK, KINGA (DMD)
Entity Type:Individual
Prefix:
First Name:KINGA
Middle Name:
Last Name:FIEDORCZUK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 S ST APT 279
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-7086
Mailing Address - Country:US
Mailing Address - Phone:510-299-3468
Mailing Address - Fax:
Practice Address - Street 1:8204 DELTA SHORES CIR S STE 140
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95832-9111
Practice Address - Country:US
Practice Address - Phone:916-277-9069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104301122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist