Provider Demographics
NPI:1346372125
Name:ZAETTA, DENEEN MARIE (OD)
Entity Type:Individual
Prefix:
First Name:DENEEN
Middle Name:MARIE
Last Name:ZAETTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-243-8999
Mailing Address - Fax:
Practice Address - Street 1:6625 LYNDALE AVE S STE 105
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423
Practice Address - Country:US
Practice Address - Phone:612-243-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOP100010152W00000X
MN3373152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0463059Medicaid
DC005264G49Medicare ID - Type Unspecified
DC0463059Medicaid