Provider Demographics
NPI:1356463327
Name:R M & M R STETZEL DDS INC
Entity Type:Organization
Organization Name:R M & M R STETZEL DDS INC
Other - Org Name:STETZEL DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:STETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-490-9949
Mailing Address - Street 1:10010 DUPONT CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1626
Mailing Address - Country:US
Mailing Address - Phone:260-490-9949
Mailing Address - Fax:260-490-3199
Practice Address - Street 1:10010 DUPONT CIRCLE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1626
Practice Address - Country:US
Practice Address - Phone:260-490-9949
Practice Address - Fax:260-490-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherTIN TAX IDENTIFICATION