Provider Demographics
NPI:1316099039
Name:WETZEL, KEVYN RICHARD (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVYN
Middle Name:RICHARD
Last Name:WETZEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9900 LINCOLN ST
Mailing Address - Street 2:2ND, FLOOR
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-4039
Mailing Address - Fax:253-968-5919
Practice Address - Street 1:9900 LINCOLN ST
Practice Address - Street 2:2ND, FLOOR
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-4039
Practice Address - Fax:253-968-5919
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8291122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist