Provider Demographics
NPI:1003339953
Name:KIM, IRENE T (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:T
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E 50TH ST APT 14A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-7941
Mailing Address - Country:US
Mailing Address - Phone:443-813-0628
Mailing Address - Fax:
Practice Address - Street 1:225 E 64TH ST STE 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6684
Practice Address - Country:US
Practice Address - Phone:212-838-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0610361223P0300X
MADN1857701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist