Healthcare Provider Details

I. General information

NPI: 1275869000
Provider Name (Legal Business Name): DAE HO KIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5929 EVERGREEN WAY STE 100
EVERETT WA
98203-6031
US

IV. Provider business mailing address

5929 EVERGREEN WAY STE 100
EVERETT WA
98203-6031
US

V. Phone/Fax

Practice location:
  • Phone: 425-353-4469
  • Fax: 425-348-5216
Mailing address:
  • Phone: 425-353-4469
  • Fax: 425-348-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60307878
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60307878
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: