Provider Demographics
NPI:1457330490
Name:HETZER, MARK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:HETZER
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 1:18905 33RD AVE W #201
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4730
Mailing Address - Country:US
Mailing Address - Phone:425-771-9090
Mailing Address - Fax:425-775-1549
Practice Address - Street 1:18905 33RD AVE W
Practice Address - Street 2:#201
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4730
Practice Address - Country:US
Practice Address - Phone:425-771-9090
Practice Address - Fax:425-775-1549
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA70511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice