Healthcare Provider Details

I. General information

NPI: 1386988913
Provider Name (Legal Business Name): FESEHATSION GEBREHIWOT FESAHA GEBREHIWOT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: FESAHA GEBREHIWOT FESAHA GEBREHIWOT

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 STEVENS AVE SW APT # O203
RENTON WA
98057-2379
US

IV. Provider business mailing address

9971 E SPEEDWAY BLVD APT # 6205
TUCSON AZ
85748-1916
US

V. Phone/Fax

Practice location:
  • Phone: 206-849-8323
  • Fax:
Mailing address:
  • Phone: 206-849-8323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE 60302987
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8625
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: