Provider Demographics
NPI:1154842797
Name:KIM, TAE YUNG (DMD)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:YUNG
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 1:505 WEST BOBIER DRIVE
Mailing Address - Street 2:APT 302
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083
Mailing Address - Country:US
Mailing Address - Phone:215-962-6316
Mailing Address - Fax:
Practice Address - Street 1:BLDG H 2005 KNIGHT LANE
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:760-725-0140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0414351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice