Provider Demographics
NPI:1962405969
Name:WALTER, KIM A (DDS)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:A
Last Name:WALTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16306 BOTHELL EVERETT HWY
Mailing Address - Street 2:STE 2
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1283
Mailing Address - Country:US
Mailing Address - Phone:425-745-4661
Mailing Address - Fax:
Practice Address - Street 1:16306 BOTHELL EVERETT HWY
Practice Address - Street 2:STE 2
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1283
Practice Address - Country:US
Practice Address - Phone:425-745-4661
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5015508Medicaid