Provider Demographics
NPI:1467702522
Name:PHAN, KIMCHI LE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIMCHI
Middle Name:LE
Last Name:PHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22727 SE 29TH ST
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-9532
Mailing Address - Country:US
Mailing Address - Phone:425-392-2103
Mailing Address - Fax:425-313-9705
Practice Address - Street 1:22727 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9532
Practice Address - Country:US
Practice Address - Phone:425-392-2103
Practice Address - Fax:425-313-9705
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist