Provider Demographics
NPI:1558703819
Name:SRISURAPOL, THIAN (DDS)
Entity Type:Individual
Prefix:
First Name:THIAN
Middle Name:
Last Name:SRISURAPOL
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 1:12819 RENTON AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98178-4849
Mailing Address - Country:US
Mailing Address - Phone:480-326-3140
Mailing Address - Fax:
Practice Address - Street 1:13346 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-3036
Practice Address - Country:US
Practice Address - Phone:206-523-6327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414951122300000X, 1223X0400X
TX312901223X0400X
WADE605748451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist