Provider Demographics
NPI:1518410471
Name:HETZLER, CAMERON
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:
Last Name:HETZLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KEEFE
Other - Middle Name:ANTHONY
Other - Last Name:HETZLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:645 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-2904
Mailing Address - Country:US
Mailing Address - Phone:212-749-1820
Mailing Address - Fax:
Practice Address - Street 1:645 10TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-2904
Practice Address - Country:US
Practice Address - Phone:212-749-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist