Individual
MATTHEW G. FETHKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
12212 W AMITY RD, BOISE, ID 83709-5389
(208) 343-4732
(208) 343-3818
Mailing address
12212 W AMITY RD, BOISE, ID 83709-5389
(208) 343-4732
(208) 343-3818
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D-3413
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6O662
BLUE CROSS OF IDAHO
ID
Enumeration date
10/02/2006
Last updated
07/08/2007
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