Healthcare Provider Details

I. General information

NPI: 1780101113
Provider Name (Legal Business Name): ELENA ANDRONOVA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 NE BOTHELL WAY STE 1
KENMORE WA
98028-9400
US

IV. Provider business mailing address

5701 NE BOTHELL WAY STE 1
KENMORE WA
98028-9400
US

V. Phone/Fax

Practice location:
  • Phone: 425-488-9785
  • Fax:
Mailing address:
  • Phone: 425-488-9785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE60742204
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: