Provider Demographics
NPI:1265403281
Name:KIM, JOHN SUNG (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14406 NE 20TH AVE
Mailing Address - Street 2:KAISER PERMANENTE SALMON CREEK DENTAL OFFICE
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1448
Mailing Address - Country:US
Mailing Address - Phone:360-571-3139
Mailing Address - Fax:
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:KAISER PERMANENTE SALMON CREEK DENTAL OFFICE
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-571-3139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000102101223G0001X
ORD88621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice