Provider Demographics
NPI:1457703001
Name:KIM, SEI JIN (DMD)
Entity Type:Individual
Prefix:
First Name:SEI
Middle Name:JIN
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 SW HARBOR WAY
Mailing Address - Street 2:UNIT 405
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5100
Mailing Address - Country:US
Mailing Address - Phone:503-810-4806
Mailing Address - Fax:
Practice Address - Street 1:742 NE DIVISION ST STE 102
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3979
Practice Address - Country:US
Practice Address - Phone:503-667-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORD110531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program