Provider Demographics
NPI:1154704658
Name:FETTERS, STEFANIE (DMD)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:FETTERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E CHOCOLATE AVE
Mailing Address - Street 2:#101
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-1334
Mailing Address - Country:US
Mailing Address - Phone:717-312-7030
Mailing Address - Fax:
Practice Address - Street 1:555 E CHOCOLATE AVE
Practice Address - Street 2:#101
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-1334
Practice Address - Country:US
Practice Address - Phone:717-312-7030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0404371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice