Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 022038 | NY |
NPI | 1043537764 |
---|---|
Provider Name | Mrs. Melanie Fetzer |
First Address | Lackawanna, NY 14218-1629 |
Second Address | Lackawanna, NY 14218-1701 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2010 |
Last Update Date | 21/04/2010 |