Provider Demographics
NPI:1780724542
Name:ETTLE, DEBRA A (DDS)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:A
Last Name:ETTLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MN
Mailing Address - Zip Code:56510-1354
Mailing Address - Country:US
Mailing Address - Phone:218-784-7119
Mailing Address - Fax:218-784-2381
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MN
Practice Address - Zip Code:56510-1354
Practice Address - Country:US
Practice Address - Phone:218-784-7119
Practice Address - Fax:218-784-2381
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice