Provider Demographics
NPI:1053083295
Name:HATEM, FAWAZ (BDS, MSD)
Entity Type:Individual
Prefix:
First Name:FAWAZ
Middle Name:
Last Name:HATEM
Suffix:
Gender:M
Credentials:BDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 231ST PL SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-6214
Mailing Address - Country:US
Mailing Address - Phone:509-539-6475
Mailing Address - Fax:
Practice Address - Street 1:13317 NE 175TH ST STE AA
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-6815
Practice Address - Country:US
Practice Address - Phone:425-321-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE.611534741223G0001X
WADENT.DE.61153474125Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No125Q00000XDental ProvidersOral Medicinist