Healthcare Provider Details

I. General information

NPI: 1063792000
Provider Name (Legal Business Name): JIMIN PARK-REEVES D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W SMITH ST STE 206
KENT WA
98032
US

IV. Provider business mailing address

7608 113TH AVE SE
NEWCASTLE WA
98056-1664
US

V. Phone/Fax

Practice location:
  • Phone: 253-854-8306
  • Fax:
Mailing address:
  • Phone: 512-461-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60437962
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60437962
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: