Provider Demographics
NPI:1477549053
Name:FETZIK, STEPHEN P (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
Last Name:FETZIK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 S SENECA
Mailing Address - Street 2:SUITE B
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-2870
Mailing Address - Country:US
Mailing Address - Phone:316-522-4765
Mailing Address - Fax:316-522-4766
Practice Address - Street 1:2860 S SENECA ST
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-2865
Practice Address - Country:US
Practice Address - Phone:316-522-4765
Practice Address - Fax:316-522-4766
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS600991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice