Provider Demographics
NPI:1225601438
Name:FETTERS, NICHOLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:FETTERS
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 1:677 7TH AVE UNIT 224
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6456
Mailing Address - Country:US
Mailing Address - Phone:815-572-1662
Mailing Address - Fax:
Practice Address - Street 1:USS TRIPOLI LHA 7
Practice Address - Street 2:UNIT 100429
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96694
Practice Address - Country:US
Practice Address - Phone:815-572-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-24
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033086122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist