Provider Demographics
NPI:1578342036
Name:KIM, JAE HWAN (DDS)
Entity Type:Individual
Prefix:
First Name:JAE HWAN
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 1:525 NE NORTHGATE WAY APT 246
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6251
Mailing Address - Country:US
Mailing Address - Phone:206-708-0877
Mailing Address - Fax:
Practice Address - Street 1:7311 NE 141ST ST STE 2
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-9703
Practice Address - Country:US
Practice Address - Phone:425-823-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE614590491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice