Provider Demographics
NPI:1679801039
Name:LIM, KENNETH PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:LIM
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 ENSIGN RD NE STE D
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5081
Mailing Address - Country:US
Mailing Address - Phone:360-570-8016
Mailing Address - Fax:360-570-8275
Practice Address - Street 1:3622 ENSIGN RD NE STE D
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5081
Practice Address - Country:US
Practice Address - Phone:360-570-8016
Practice Address - Fax:360-570-8275
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60459097122300000X, 1223G0001X
AK13241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0046Medicaid
WA2039082Medicaid