Provider Demographics
NPI:1598886582
Name:STETZEL, MARK R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:STETZEL
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 1:10010 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
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice