MEDICARE: NIMA FOROUTAN DDS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DE60384118	WA

General Provider Information

NPI Number	:	1699130211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIMA FOROUTAN DDS PLLC

Provider Business Mailing Address
First Line	:	410 BELLEVUE WAY SE STE 102
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98004-6649
Country	:	US
Telephone Number	:	425-454-3833
Fax Number	:	425-635-9312

Provider Business Practice Location Address
First Line	:	410 BELLEVUE WAY SE STE 102
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98004-6649
Country	:	US
Telephone Number	:	425-454-3833
Fax Number	:	425-635-9312

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. NIMA FOROUTAN
Credential	:
Telephone Number	:	425-786-8879

Provider Enumeration Date	:	12/24/2015
Last Update Date	:	12/24/2015

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