Provider Demographics
NPI:1790740322
Name:ETZENBACH, JOHN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:ETZENBACH
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 1:1 JARRETT WHITE RD BLDG 320
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:TRIPLER AMC
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:808-433-9200
Mailing Address - Fax:808-433-9194
Practice Address - Street 1:1 JARRETT WHITE RD BLDG 320
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-9200
Practice Address - Fax:808-433-9194
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190181771223P0300X
HI21921223P0300X
CA528151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics