Provider Demographics
NPI:1528348695
Name:KIM, SAM DK (DMD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:DK
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 SW 43RD ST STE 109
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4803
Mailing Address - Country:US
Mailing Address - Phone:253-277-8767
Mailing Address - Fax:253-277-8769
Practice Address - Street 1:1412 SW 43RD ST
Practice Address - Street 2:IDC MEDICAL PLAZA, #109
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4803
Practice Address - Country:US
Practice Address - Phone:253-277-8767
Practice Address - Fax:253-277-8769
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601278821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice