Provider Demographics
NPI:1487685376
Name:ERNAFASOV, TIMUR (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMUR
Middle Name:
Last Name:ERNAFASOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12549 ROOSEVELT WAY NE APT 7
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-3973
Mailing Address - Country:US
Mailing Address - Phone:253-852-6080
Mailing Address - Fax:253-852-6099
Practice Address - Street 1:610 W MEEKER ST
Practice Address - Street 2:SUITE #102
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5726
Practice Address - Country:US
Practice Address - Phone:253-852-6080
Practice Address - Fax:253-852-6099
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047519Medicaid