Provider Demographics
NPI:1992856348
Name:KIM, ERIC N (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:N
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 1:300 SE 120TH AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4020
Mailing Address - Country:US
Mailing Address - Phone:360-993-0300
Mailing Address - Fax:360-750-8956
Practice Address - Street 1:300 SE 120TH AVE STE 600
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4020
Practice Address - Country:US
Practice Address - Phone:360-993-0300
Practice Address - Fax:360-750-8956
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR80011223G0001X
WADE60294690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice