Provider Demographics
NPI:1083978266
Name:KIM, JOHN W (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 HIGHWAY 85 N STE A
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2085
Mailing Address - Country:US
Mailing Address - Phone:407-587-9665
Mailing Address - Fax:
Practice Address - Street 1:1135 HIGHWAY 85 N STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2085
Practice Address - Country:US
Practice Address - Phone:407-587-9665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19740122300000X, 1223G0001X
GADN1225461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist