Provider Demographics
NPI:1053519041
Name:FOTEK, ILONA (DMD,MS)
Entity type:Individual
Prefix:
First Name:ILONA
Middle Name:
Last Name:FOTEK
Suffix:
Gender:F
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LA VIDA CT
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-1720
Mailing Address - Country:US
Mailing Address - Phone:561-779-7058
Mailing Address - Fax:
Practice Address - Street 1:1401 FORUM WAY STE 800
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2322
Practice Address - Country:US
Practice Address - Phone:561-327-6664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN179821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice