Provider Demographics
NPI:1154487445
Name:KIM, SEONGRYEOL ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:SEONGRYEOL
Middle Name:ALBERT
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11825 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525
Mailing Address - Country:US
Mailing Address - Phone:309-243-1541
Mailing Address - Fax:309-243-8188
Practice Address - Street 1:3505 NW ANDERSON HILL RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9161
Practice Address - Country:US
Practice Address - Phone:360-337-1780
Practice Address - Fax:309-243-8188
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010423122300000X
IL019028319122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist