Provider Demographics
NPI:1114906575
Name:KIM, SANDRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 ONTARIO RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-2627
Mailing Address - Country:US
Mailing Address - Phone:202-483-4922
Mailing Address - Fax:
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8323
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:703-680-7953
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15220122300000X
VA0401412651122300000X
DCDEN1000804122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200285280Medicaid