Provider Demographics
NPI:1639894652
Name:KIM, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3627
Mailing Address - Country:US
Mailing Address - Phone:360-748-1833
Mailing Address - Fax:360-748-3807
Practice Address - Street 1:68 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3627
Practice Address - Country:US
Practice Address - Phone:360-748-1833
Practice Address - Fax:360-748-3807
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61323747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist