Provider Demographics
NPI:1942398524
Name:FETTIG, SHAWN MIKEAL (LD)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:MIKEAL
Last Name:FETTIG
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 NE 114 AVE
Mailing Address - Street 2:#K6
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4289
Mailing Address - Country:US
Mailing Address - Phone:360-892-7107
Mailing Address - Fax:360-891-8361
Practice Address - Street 1:2701 NE 114 AVE
Practice Address - Street 2:#K6
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4289
Practice Address - Country:US
Practice Address - Phone:360-892-7107
Practice Address - Fax:360-891-8361
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAON00000393122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047576Medicaid