Provider Demographics
NPI:1053363978
Name:FEDELEM, GERALD LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:LEE
Last Name:FEDELEM
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 1:4410 DELAWARE RD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-9755
Mailing Address - Country:US
Mailing Address - Phone:231-924-5454
Mailing Address - Fax:
Practice Address - Street 1:663 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-9708
Practice Address - Country:US
Practice Address - Phone:231-924-0790
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010099351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice