Provider Demographics
NPI:1730315375
Name:FOTOVATJAH, HOMAYOON (DDS)
Entity Type:Individual
Prefix:DR
First Name:HOMAYOON
Middle Name:
Last Name:FOTOVATJAH
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 1:1314 UNION AVE NE
Mailing Address - Street 2:#8
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3959
Mailing Address - Country:US
Mailing Address - Phone:425-227-9774
Mailing Address - Fax:
Practice Address - Street 1:1314 UNION AVE NE
Practice Address - Street 2:#8
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98059-3959
Practice Address - Country:US
Practice Address - Phone:425-227-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000068541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5019823Medicaid