Provider Demographics
NPI:1497002133
Name:FETZIK DENTISTRY LLC
Entity Type:Organization
Organization Name:FETZIK DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FETZIK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:316-440-4432
Mailing Address - Street 1:2548 N MAIZE CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-7347
Mailing Address - Country:US
Mailing Address - Phone:316-440-4432
Mailing Address - Fax:316-522-4766
Practice Address - Street 1:2548 N MAIZE CT
Practice Address - Street 2:SUITE 100
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-7347
Practice Address - Country:US
Practice Address - Phone:316-440-4432
Practice Address - Fax:316-522-4766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60099122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty