MEDICARE: PETER E. KIM, DDS, PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	DE 60468228	WA

General Provider Information

NPI Number	:	1457751273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER E. KIM, DDS, PS

Provider Business Mailing Address
First Line	:	2100 E SECTION ST STE 103
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-9132
Country	:	US
Telephone Number	:	360-424-7057
Fax Number	:	360-424-7058

Provider Business Practice Location Address
First Line	:	2100 E SECTION ST STE 103
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-9132
Country	:	US
Telephone Number	:	360-424-7057
Fax Number	:	360-424-7058

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PETER E KIM
Credential	:	DDS
Telephone Number	:	513-802-2799

Provider Enumeration Date	:	08/28/2014
Last Update Date	:	08/28/2014

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