Provider Demographics
NPI:1932512647
Name:PAEK, AGELINA
Entity Type:Individual
Prefix:
First Name:AGELINA
Middle Name:
Last Name:PAEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8661 NE 123RD PL
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6030
Mailing Address - Country:US
Mailing Address - Phone:425-691-7289
Mailing Address - Fax:
Practice Address - Street 1:6942 ALMADEN EXPY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-3201
Practice Address - Country:US
Practice Address - Phone:408-770-9383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1002311223P0221X
CT0113291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223P0221XDental ProvidersDentistPediatric Dentistry