NPIMap

Organization Active NPI

Susan Kim DDS

  • Pediatric Dentistry
  • Kirkland, WA
National Provider Identifier
1265495196
Registry record updated Jul 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
9731 Issued in WA
Legal business name
SUSAN KIM DDS
Practice address
12910 Totem Lake Blvd NE Ste 103
Kirkland, WA 98034
Phone
(425) 814-3196
Fax
(425) 825-9646
NPI assigned
Apr 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 17, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Susan S Kim, DDSNPI 1033219936
Title
President
Phone
(425) 814-3196

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 9731 WA Primary

Addresses

Primary practice location

12910 Totem Lake Blvd NE Ste 103
Kirkland, WA 98034

Mailing address

12910 Totem Lake Blvd NE Ste 103
Kirkland, WA 98034-2901
Phone (425) 814-3196

Other identifiers 1

IdentifierTypeStateIssuer
5048368MedicaidWA

Other names 1

  • Evergreen Pediatric Dentistry Doing business as

National Provider Directory

National Provider Directory

Locations

12910 Totem Lake Blvd NE
Ste 103
Kirkland, WA 98034
Phone (425) 814-3196

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1144713600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1531785600000",
    "number": "1265495196",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12910 TOTEM LAKE BLVD NE STE 103",
            "city": "KIRKLAND",
            "state": "WA",
            "postal_code": "980342901",
            "telephone_number": "425-814-3196",
            "fax_number": "425-825-9646"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12910 TOTEM LAKE BLVD NE STE 103",
            "city": "KIRKLAND",
            "state": "WA",
            "postal_code": "98034",
            "telephone_number": "425-814-3196",
            "fax_number": "425-825-9646"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUSAN KIM DDS",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-11",
        "last_updated": "2018-07-17",
        "status": "A",
        "authorized_official_last_name": "KIM",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "425-814-3196",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "WA",
            "license": "9731",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5048368",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Pediatric Dentistry",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Evergreen Pediatric Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kirkland, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.