Provider Demographics
NPI:1073807103
Name:KIM, SEAN SHIN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:SHIN
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 1:426 PLATEAU AVE # 2
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1726
Mailing Address - Country:US
Mailing Address - Phone:201-600-6704
Mailing Address - Fax:
Practice Address - Street 1:152 N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4046
Practice Address - Country:US
Practice Address - Phone:631-226-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist