Provider Demographics
NPI:1407001647
Name:LISA PARK DDS & SIMONE KIM DDS
Entity Type:Organization
Organization Name:LISA PARK DDS & SIMONE KIM DDS
Other - Org Name:FREMONT DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-675-0366
Mailing Address - Street 1:3601 FREMONT AVE N
Mailing Address - Street 2:SUITE 316
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-2709
Mailing Address - Country:US
Mailing Address - Phone:206-675-0366
Mailing Address - Fax:206-675-0466
Practice Address - Street 1:3601 FREMONT AVE N
Practice Address - Street 2:SUITE 316
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-2709
Practice Address - Country:US
Practice Address - Phone:206-675-0366
Practice Address - Fax:206-675-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7430949451223G0001X
WA7430949481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty