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General NPI Number Information
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NPI Number | 1215038716
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Entity Type | Individual
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Provider Name | WALTER FOMBIN FOTO BDS DMD
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Gender | Male
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 4202 10TH ST SE # 101
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City | PUYALLUP
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State | WA
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Zip | 98374-2191
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Country | US
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Telephone | 253-272-7574
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Fax | 253-272-9044
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Provider Business Mailing Address
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Address Line | 4202 10TH ST SE STE 311
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City | PUYALLUP
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State | WA
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Zip | 98374-2191
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Country | US
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Telephone | 253-272-7574
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Fax | 253-272-9044
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 8264
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License Number State | WA
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