Provider Demographics
NPI:1063853000
Name:FETTIG, ALEAHA (DDS)
Entity Type:Individual
Prefix:
First Name:ALEAHA
Middle Name:
Last Name:FETTIG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 4TH ST NW
Mailing Address - Street 2:SUITE 13
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5761
Mailing Address - Country:US
Mailing Address - Phone:505-821-5437
Mailing Address - Fax:505-821-8041
Practice Address - Street 1:6211 4TH ST NW
Practice Address - Street 2:SUITE 13
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5761
Practice Address - Country:US
Practice Address - Phone:505-821-5437
Practice Address - Fax:505-821-8041
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-06
Last Update Date:2013-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist