Provider Demographics
NPI:1003977653
Name:KIM, RICHARD HYUNGSANG (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HYUNGSANG
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 PREMIERE DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5900
Mailing Address - Country:US
Mailing Address - Phone:507-625-9330
Mailing Address - Fax:507-625-1440
Practice Address - Street 1:1990 PREMIERE DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5900
Practice Address - Country:US
Practice Address - Phone:507-625-9330
Practice Address - Fax:507-625-1440
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113631223S0112X
MN1006801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN355K4KIOtherBLUE CROSS
MN355K4KIOtherBLUE CROSS