Healthcare Provider Details

I. General information

NPI: 1164089769
Provider Name (Legal Business Name): KAMRAN FOTOOHI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 112TH ST SW
EVERETT WA
98204-4875
US

IV. Provider business mailing address

1019 112TH ST SW
EVERETT WA
98204-4875
US

V. Phone/Fax

Practice location:
  • Phone: 425-551-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE61052139
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE61052139
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: