Provider Demographics
NPI:1518318781
Name:FEDUSENKO, JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:FEDUSENKO
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 1:3326 JENKINS RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1597
Mailing Address - Country:US
Mailing Address - Phone:423-521-1984
Mailing Address - Fax:
Practice Address - Street 1:3326 JENKINS RD STE 103
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1597
Practice Address - Country:US
Practice Address - Phone:423-521-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN104891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice