Provider Demographics
NPI:1790096766
Name:FOTOVAT, MARK JONATHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JONATHAN
Last Name:FOTOVAT
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 1:6671 SMOKE RANCH RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-8419
Mailing Address - Country:US
Mailing Address - Phone:702-869-8031
Mailing Address - Fax:
Practice Address - Street 1:6671 SMOKE RANCH RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-8419
Practice Address - Country:US
Practice Address - Phone:702-869-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV61931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice