Provider Demographics
NPI:1275606303
Name:FERNUNSON, MARTIN A (DDS)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:FERNUNSON
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 1:11511 NE 195TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-5769
Mailing Address - Country:US
Mailing Address - Phone:425-481-5302
Mailing Address - Fax:
Practice Address - Street 1:11511 NE 195TH ST STE 104
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-5769
Practice Address - Country:US
Practice Address - Phone:425-481-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADEN000105211223G0001X
WADE000105211223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice