Provider Demographics
NPI:1104845841
Name:KIM, JUNG KI X (DDS,PS)
Entity Type:Individual
Prefix:DR
First Name:JUNG
Middle Name:KI
Last Name:KIM
Suffix:X
Gender:M
Credentials:DDS,PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0058
Mailing Address - Country:US
Mailing Address - Phone:509-837-3292
Mailing Address - Fax:509-837-3448
Practice Address - Street 1:1519 E EDISON AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-1624
Practice Address - Country:US
Practice Address - Phone:509-837-3292
Practice Address - Fax:509-837-3448
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000067391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA49548OtherL&I
WA867897OtherUNITED CONCORDIA
WA5013594Medicaid