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General NPI Number Information
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NPI Number | 1942398524
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Entity Type | Individual
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Provider Name | SHAWN MIKEAL FETTIG LD
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Gender | Male
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Dates
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Enumeration Date | 10/10/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2701 NE 114 AVE #K6
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City | VANCOUVER
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State | WA
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Zip | 98684-4289
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Country | US
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Telephone | 360-892-7107
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Fax | 360-891-8361
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Provider Business Mailing Address
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Address Line | 2701 NE 114 AVE #K6
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City | VANCOUVER
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State | WA
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Zip | 98684-4289
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Country | US
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Telephone | 360-892-7107
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Fax | 360-891-8361
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | ON00000393
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License Number State | WA
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