MEDICARE: DR. MARK T HETZER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7051	WA

General Provider Information

NPI Number	:	1457330490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK T HETZER DDS

Provider Business Mailing Address
First Line	:	18905 33RD AVE W #201
Second Line	:
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-4730
Country	:	US
Telephone Number	:	425-771-9090
Fax Number	:	425-775-1549

Provider Business Practice Location Address
First Line	:	18905 33RD AVE W
Second Line	:	#201
City	:	LYNNWOOD
State	:	WA
Zip	:	98036-4730
Country	:	US
Telephone Number	:	425-771-9090
Fax Number	:	425-775-1549

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	07/08/2007

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