Provider Demographics
NPI:1851844427
Name:KWON, JAIMIE
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 ELLIOTT AVE W
Mailing Address - Street 2:SUITE 212
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-3645
Mailing Address - Country:US
Mailing Address - Phone:206-812-7957
Mailing Address - Fax:
Practice Address - Street 1:945 ELLIOTT AVE W
Practice Address - Street 2:SUITE 212
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-3645
Practice Address - Country:US
Practice Address - Phone:206-812-7957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE606728101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice