Healthcare Provider Details

I. General information

NPI: 1053672022
Provider Name (Legal Business Name): JAE SEON KIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 WESTLAKE AVE N STE 204
SEATTLE WA
98109-2753
US

IV. Provider business mailing address

2046 WESTLAKE AVE N STE 204
SEATTLE WA
98109-2753
US

V. Phone/Fax

Practice location:
  • Phone: 206-284-4505
  • Fax: 206-284-4757
Mailing address:
  • Phone: 206-284-4505
  • Fax: 206-284-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE60223220
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: