Provider Demographics
NPI:1093858318
Name:KIM, PETER H (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:H
Last Name:KIM
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 1:16410 SMOKEY POINT BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-8415
Mailing Address - Country:US
Mailing Address - Phone:360-651-1359
Mailing Address - Fax:360-659-1275
Practice Address - Street 1:16410 SMOKEY POINT BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8415
Practice Address - Country:US
Practice Address - Phone:360-651-1359
Practice Address - Fax:360-659-1275
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000086561223S0112X
WAGA100002821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA141618OtherLABOR & INDUSTRIES
WA5034640Medicaid
WA141618OtherLABOR & INDUSTRIES
WAAB38711Medicare ID - Type UnspecifiedMEDICARE INDIVDUAL PROVID