Provider Demographics
NPI:1124196209
Name:KIM, CHOL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHOL
Middle Name:
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 1:2494 JETT FERRY RD
Mailing Address - Street 2:STE 101
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3090
Mailing Address - Country:US
Mailing Address - Phone:770-393-1524
Mailing Address - Fax:770-393-1572
Practice Address - Street 1:2494 JETT FERRY RD
Practice Address - Street 2:STE101
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-3090
Practice Address - Country:US
Practice Address - Phone:770-393-1524
Practice Address - Fax:770-393-1572
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049427-11223G0001X
GADN0134791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02226828Medicaid