Provider Demographics
NPI:1063030500
Name:KIM, SANGWOON
Entity Type:Individual
Prefix:
First Name:SANGWOON
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:PSC 2 BOX 686
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96264-0007
Mailing Address - Country:US
Mailing Address - Phone:909-764-8408
Mailing Address - Fax:
Practice Address - Street 1:31ST MEDICAL GROUP/SGHC
Practice Address - Street 2:UNIT 6180
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604
Practice Address - Country:US
Practice Address - Phone:043-430-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0258661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice