Provider Demographics
NPI:1780913764
Name:KAWAKUBO, KOZUE (DMD)
Entity type:Individual
Prefix:
First Name:KOZUE
Middle Name:
Last Name:KAWAKUBO
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 1:17130 AVONDALE WAY NE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-4455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17130 AVONDALE WAY NE
Practice Address - Street 2:SUITE 118
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4455
Practice Address - Country:US
Practice Address - Phone:425-869-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15250122300000X
WADE605878931223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist