Provider Demographics
NPI:1972804037
Name:KIM, CHAN BAE (DDS)
Entity type:Individual
Prefix:
First Name:CHAN
Middle Name:BAE
Last Name:KIM
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 1:30640 PACIFIC HWY S STE A
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4889
Mailing Address - Country:US
Mailing Address - Phone:253-946-3895
Mailing Address - Fax:
Practice Address - Street 1:30640 PACIFIC HWY S STE A
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4889
Practice Address - Country:US
Practice Address - Phone:253-946-3895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60483705122300000X
OK62501223G0001X
CA595741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice