Provider Demographics
NPI:1063792000
Name:PARK-REEVES, JIMIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JIMIN
Middle Name:
Last Name:PARK-REEVES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7608 113TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98056-1664
Mailing Address - Country:US
Mailing Address - Phone:512-461-2182
Mailing Address - Fax:
Practice Address - Street 1:655 W SMITH ST STE 206
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032
Practice Address - Country:US
Practice Address - Phone:253-854-8306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604379621223G0001X
WADE604379621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice