Provider Demographics
NPI:1275869000
Name:KIM, DAE HO (DDS)
Entity Type:Individual
Prefix:
First Name:DAE HO
Middle Name:
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 1:5929 EVERGREEN WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-6031
Mailing Address - Country:US
Mailing Address - Phone:425-353-4469
Mailing Address - Fax:425-348-5216
Practice Address - Street 1:5929 EVERGREEN WAY STE 100
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-6031
Practice Address - Country:US
Practice Address - Phone:425-353-4469
Practice Address - Fax:425-348-5216
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE603078781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019027981Medicaid