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General NPI Number Information
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NPI Number | 1497002133
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Entity Type | Organization
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Legal Business Name | FETZIK DENTISTRY LLC
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Dates
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Enumeration Date | 08/13/2012
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Last Update Date | 08/13/2012
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Provider Practice Location Address
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Address Line | 2548 N MAIZE CT SUITE 100
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City | WICHITA
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State | KS
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Zip | 67205-7347
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Country | US
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Telephone | 316-440-4432
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Fax | 316-522-4766
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Provider Business Mailing Address
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Address Line | 2548 N MAIZE CT SUITE 100
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City | WICHITA
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State | KS
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Zip | 67205-7347
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Country | US
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Telephone | 316-440-4432
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Fax | 316-522-4766
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEPHEN P FETZIK
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Credential | DMD
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Telephone | 316-440-4432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 60099
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License Number State | KS
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