Healthcare Provider Details

I. General information

NPI: 1255873345
Provider Name (Legal Business Name): SHIWOO KIM D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15823 WESTMINSTER WAY N
SHORELINE WA
98133-5928
US

IV. Provider business mailing address

15823 WESTMINSTER WAY
N SHORELINE WA
98113-4761
US

V. Phone/Fax

Practice location:
  • Phone: 213-590-5686
  • Fax:
Mailing address:
  • Phone: 213-590-5686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS100351
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE61424421
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: