Provider Demographics
NPI:1225599111
Name:FOTENE GENNATOS DDS, PLLC
Entity Type:Organization
Organization Name:FOTENE GENNATOS DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FOTENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GENNATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-451-6174
Mailing Address - Street 1:3008 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-4063
Mailing Address - Country:US
Mailing Address - Phone:406-451-6174
Mailing Address - Fax:
Practice Address - Street 1:415 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1725
Practice Address - Country:US
Practice Address - Phone:712-732-2277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental