Provider Demographics
NPI:1649395104
Name:FEDORCIW, ROMAN J (DDS)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:J
Last Name:FEDORCIW
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 1:26 SHUNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416
Mailing Address - Country:US
Mailing Address - Phone:860-635-4666
Mailing Address - Fax:860-635-3621
Practice Address - Street 1:26 SHUNPIKE RD
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416
Practice Address - Country:US
Practice Address - Phone:860-635-4666
Practice Address - Fax:860-635-3621
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7706122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist