Provider Demographics
NPI:1831240852
Name:FEDELE, MICHAEL F (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:F
Last Name:FEDELE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 MULBERRY ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1500
Mailing Address - Country:US
Mailing Address - Phone:570-346-0700
Mailing Address - Fax:570-983-0004
Practice Address - Street 1:426 MULBERRY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1500
Practice Address - Country:US
Practice Address - Phone:570-346-0700
Practice Address - Fax:570-983-0004
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027174 L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA402094OtherUNITED CONCORDIA INSURANC
PA800648OtherFIRST PRIORITY INSURANCE
PA0015635300003Medicaid
PA800648OtherFIRST PRIORITY INSURANCE