Provider Demographics
NPI:1841450889
Name:MATTHEW G. FETHKE, D.D.S.,PC
Entity type:Organization
Organization Name:MATTHEW G. FETHKE, D.D.S.,PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:D
Authorized Official - Last Name:HEFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-343-4732
Mailing Address - Street 1:12212 W AMITY RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5389
Mailing Address - Country:US
Mailing Address - Phone:208-343-4732
Mailing Address - Fax:208-343-3818
Practice Address - Street 1:12212 W AMITY RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5389
Practice Address - Country:US
Practice Address - Phone:208-343-4732
Practice Address - Fax:208-343-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD34131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1447343488OtherNPI