Provider Demographics
NPI:1972218410
Name:FOTOUHI, STEPHANIE MARIE (DDS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:FOTOUHI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 N UNIVERSITY AVE RM 2075
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:734-764-1523
Mailing Address - Fax:
Practice Address - Street 1:4615 STONELEIGH RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-2165
Practice Address - Country:US
Practice Address - Phone:248-331-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601370122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist