Provider Demographics
NPI:1982719175
Name:FOTOVAT, MEHDI (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEHDI
Middle Name:
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 1:5445 LAUREL CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-4661
Mailing Address - Country:US
Mailing Address - Phone:818-980-5300
Mailing Address - Fax:818-980-3464
Practice Address - Street 1:5445 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-4661
Practice Address - Country:US
Practice Address - Phone:818-980-5300
Practice Address - Fax:818-980-3464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA382811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics