Provider Demographics
NPI:1639894652
Name:KIM, MAX
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COOPER POINT RD SW STE 23
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1179
Mailing Address - Country:US
Mailing Address - Phone:360-352-1330
Mailing Address - Fax:
Practice Address - Street 1:1800 COOPER POINT RD SW STE 23
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1179
Practice Address - Country:US
Practice Address - Phone:360-352-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61323747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist