Provider Demographics
NPI:1598875874
Name:KIM, LISA C (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:KIM
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 1:1811 156TH AVE NE
Mailing Address - Street 2:# 4
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-4344
Mailing Address - Country:US
Mailing Address - Phone:425-747-6580
Mailing Address - Fax:425-747-6548
Practice Address - Street 1:1811 156TH AVE NE
Practice Address - Street 2:# 4
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-4344
Practice Address - Country:US
Practice Address - Phone:425-747-6580
Practice Address - Fax:425-747-6548
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007420122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist