Provider Demographics
NPI:1184638256
Name:KIM, SUKHO (LICENSED DENTURIST)
Entity Type:Individual
Prefix:MR
First Name:SUKHO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LICENSED DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 232ND ST SW
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-4738
Mailing Address - Country:US
Mailing Address - Phone:425-712-0915
Mailing Address - Fax:
Practice Address - Street 1:5506 232ND ST SW
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-4738
Practice Address - Country:US
Practice Address - Phone:425-712-0915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000041122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5021282Medicaid