Provider Demographics
NPI:1265182331
Name:FOZETTIAKO, ALAIN (RDH)
Entity type:Individual
Prefix:
First Name:ALAIN
Middle Name:
Last Name:FOZETTIAKO
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST DNBN ATTN: CREDENTIALS
Mailing Address - Street 2:BOX 555221
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5221
Mailing Address - Country:US
Mailing Address - Phone:210-367-7096
Mailing Address - Fax:
Practice Address - Street 1:8085 SAND HILL RD APT A
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-5597
Practice Address - Country:US
Practice Address - Phone:210-367-7096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26943124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist