Provider Demographics
NPI:1073687265
Name:DENTAL ASSOCIATES OF BRYN MAWR
Entity Type:Organization
Organization Name:DENTAL ASSOCIATES OF BRYN MAWR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:INSUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-463-1212
Mailing Address - Street 1:3224 W BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3606
Mailing Address - Country:US
Mailing Address - Phone:773-463-1212
Mailing Address - Fax:
Practice Address - Street 1:3224 W BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3606
Practice Address - Country:US
Practice Address - Phone:773-463-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty