Provider Demographics
NPI:1639553795
Name:KIM, KYUAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYUAN
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 1:317 112TH AVE NE
Mailing Address - Street 2:APT 801
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5824
Mailing Address - Country:US
Mailing Address - Phone:217-979-3943
Mailing Address - Fax:
Practice Address - Street 1:15224 MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-7332
Practice Address - Country:US
Practice Address - Phone:425-379-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA606984621223G0001X
IN12012380A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice