Provider Demographics
NPI:1255429544
Name:FETTER, KENNETH ALLEN SR (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLEN
Last Name:FETTER
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-4202
Mailing Address - Country:US
Mailing Address - Phone:610-688-4578
Mailing Address - Fax:610-995-2355
Practice Address - Street 1:415 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-4202
Practice Address - Country:US
Practice Address - Phone:610-688-4578
Practice Address - Fax:610-995-2355
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020477122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist