1316099039 NPI number — DR. KEVYN RICHARD WETZEL DMD

Table of content: DR. KEVYN RICHARD WETZEL DMD (NPI 1316099039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316099039 NPI number — DR. KEVYN RICHARD WETZEL DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WETZEL
Provider First Name:
KEVYN
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316099039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9900 LINCOLN ST
Provider Second Line Business Mailing Address:
2ND, FLOOR
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98431-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-968-4039
Provider Business Mailing Address Fax Number:
253-968-5919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9900 LINCOLN ST
Provider Second Line Business Practice Location Address:
2ND, FLOOR
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-4039
Provider Business Practice Location Address Fax Number:
253-968-5919
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D8291 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: D8291 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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