=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558416586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIM AUN DDS PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2607 BRIDGEPORT WAY W SUITE 1K
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98466-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-564-2701
-----------------------------------------------------
Fax | 253-566-3638
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2607 BRIDGEPORT WAY W SUITE 1K
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98466-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-564-2701
-----------------------------------------------------
Fax | 253-566-3638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PRASITH KIM-AUN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 253-564-2701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE9609
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE9156
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------