Provider Demographics
NPI:1215038716
Name:FOTO, WALTER FOMBIN (BDS DMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:FOMBIN
Last Name:FOTO
Suffix:
Gender:M
Credentials:BDS DMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4202 10TH ST SE STE 311
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2191
Mailing Address - Country:US
Mailing Address - Phone:253-272-7574
Mailing Address - Fax:253-272-9044
Practice Address - Street 1:4202 10TH ST SE # 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2191
Practice Address - Country:US
Practice Address - Phone:253-272-7574
Practice Address - Fax:253-272-9044
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA82641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty