Healthcare Provider Details

I. General information

NPI: 1457751273
Provider Name (Legal Business Name): PETER E. KIM, DDS, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E SECTION ST STE 103
MOUNT VERNON WA
98274-9132
US

IV. Provider business mailing address

2100 E SECTION ST STE 103
MOUNT VERNON WA
98274-9132
US

V. Phone/Fax

Practice location:
  • Phone: 360-424-7057
  • Fax: 360-424-7058
Mailing address:
  • Phone: 360-424-7057
  • Fax: 360-424-7058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDE 60468228
License Number StateWA

VIII. Authorized Official

Name: PETER E KIM
Title or Position: PRESIDENT
Credential: DDS
Phone: 513-802-2799