Provider Demographics
NPI:1174076004
Name:FEDOR, GRACE CATHERINE (DDS)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:CATHERINE
Last Name:FEDOR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:LIU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11253 MIRO CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3313
Mailing Address - Country:US
Mailing Address - Phone:661-203-4417
Mailing Address - Fax:
Practice Address - Street 1:5638 MISSION CENTER RD
Practice Address - Street 2:STE 107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4348
Practice Address - Country:US
Practice Address - Phone:619-220-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10005501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice