Healthcare Provider Details

I. General information

NPI: 1942398524
Provider Name (Legal Business Name): SHAWN MIKEAL FETTIG LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 NE 114 AVE #K6
VANCOUVER WA
98684-4289
US

IV. Provider business mailing address

2701 NE 114 AVE #K6
VANCOUVER WA
98684-4289
US

V. Phone/Fax

Practice location:
  • Phone: 360-892-7107
  • Fax: 360-891-8361
Mailing address:
  • Phone: 360-892-7107
  • Fax: 360-891-8361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberON00000393
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: