Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | ON00000393 | WA |
NPI | 1942398524 |
---|---|
Provider Name | Mr. Shawn Mikeal Fettig |
First Address | Vancouver, WA 98684-4289 |
Second Address | Vancouver, WA 98684-4289 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5047576 | (05) | WA |