Provider Demographics
NPI:1083911846
Name:KIM, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
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:PO BOX 840925
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0641
Mailing Address - Country:US
Mailing Address - Phone:972-361-0600
Mailing Address - Fax:
Practice Address - Street 1:2722 W GRAND PKWY N # 200
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449
Practice Address - Country:US
Practice Address - Phone:832-906-3108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA586991223P0300X
TX298941223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics