Provider Demographics
NPI:1093169344
Name:KIM, SU JIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SU
Middle Name:JIN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 W BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2029 SUFFOLK RD STE B
Practice Address - Street 2:
Practice Address - City:FINKSBURG
Practice Address - State:MD
Practice Address - Zip Code:21048-1630
Practice Address - Country:US
Practice Address - Phone:410-861-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD166471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program