Provider Demographics
NPI:1316265002
Name:SUNSET DENTAL CENTER
Entity type:Organization
Organization Name:SUNSET DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOMAYOON
Authorized Official - Middle Name:
Authorized Official - Last Name:FOTOVATJAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-227-9774
Mailing Address - Street 1:1314 UNION AVE NE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3959
Mailing Address - Country:US
Mailing Address - Phone:425-227-9774
Mailing Address - Fax:
Practice Address - Street 1:1314 UNION AVE NE
Practice Address - Street 2:SUITE 8
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98059-3959
Practice Address - Country:US
Practice Address - Phone:425-227-9774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 00006854122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5019823Medicaid