=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528797180
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIM PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2022
-----------------------------------------------------
Last Update Date | 06/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19106 33RD AVE W STE 1
-----------------------------------------------------
City | LYNNWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98036-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-775-5411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13120 NE 112TH ST
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98033-4102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-940-7769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DONGKOOK DENNIS LIM
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 626-344-9678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------