Provider Demographics
NPI:1447343488
Name:FETHKE, MATTHEW G (DDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:FETHKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-34131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6O662OtherBLUE CROSS OF IDAHO