Provider Demographics
NPI:1215019799
Name:ZETZ, MICHAEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:ZETZ
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 1:4181 HOLIDAY ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2531
Mailing Address - Country:US
Mailing Address - Phone:330-493-1605
Mailing Address - Fax:330-493-9308
Practice Address - Street 1:4181 HOLIDAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2531
Practice Address - Country:US
Practice Address - Phone:330-493-1605
Practice Address - Fax:330-493-9308
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0171111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0524534Medicaid
OHZE0539243Medicare ID - Type Unspecified
OHZE0539242Medicare ID - Type Unspecified
OH0524534Medicaid