=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619059185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN C FETNER DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 N ALSTON ST
-----------------------------------------------------
City | FOLEY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36535-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-943-8547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4635 STARBOARD LN
-----------------------------------------------------
City | ORANGE BEACH
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5494
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------