Healthcare Provider Details

I. General information

NPI: 1053083295
Provider Name (Legal Business Name): FAWAZ HATEM BDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11540 15TH AVE NE
SEATTLE WA
98125-6322
US

IV. Provider business mailing address

3608 231ST PL SE
BOTHELL WA
98021-6214
US

V. Phone/Fax

Practice location:
  • Phone: 206-440-1500
  • Fax:
Mailing address:
  • Phone: 509-539-6475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE.61153474
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code125Q00000X
TaxonomyOral Medicine Dentistry
License NumberDENT.DE.61153474
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: