Prime Dental Group, LLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DE00011116 Issued in WA

Legal business name

PRIME DENTAL GROUP, LLC

Practice address

302 Washington Ave S
Kent, WA 98032-5713

Phone

(253) 520-3866

Fax

(253) 520-3844

NPI assigned

Mar 16, 2009

Organization subpart

No

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

Authorized official

Name

Yongjae Kim, DDS

Title

Member

Phone

(425) 457-3638

Specialties & licenses 2

Addresses

Other identifiers 1

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

{
    "created_epoch": "1237161600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1256169600000",
    "number": "1407097850",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 4086",
            "city": "BELLEVUE",
            "state": "WA",
            "postal_code": "980094086"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "302 WASHINGTON AVE S",
            "city": "KENT",
            "state": "WA",
            "postal_code": "980325713",
            "telephone_number": "253-520-3866",
            "fax_number": "253-520-3844"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIME DENTAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-03-16",
        "last_updated": "2009-10-22",
        "status": "A",
        "authorized_official_last_name": "KIM",
        "authorized_official_first_name": "YONGJAE",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "425-457-3638",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "DE00011116",
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "DE00011115",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5059373",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Carol Preble
• Mariana Preda, CNA
• Kristina Lyn Pribble, RPH
• Jonah Price
• Tiana Leah Price, RN
• Vonda K Prioleau, LMP
• Pristine House LLC
• Pro Med Alliance Medical Staffing
• Kristine Marie Proctor, LMP,MMP
• Proliance Surgeons Inc., P.S.

• General Practice Dentistry in Kent, WA
• Providers in Kent, WA by specialty
• General Practice Dentistry in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2009; 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.