Provider Demographics
NPI:1164622635
Name:KIM, SORA
Entity Type:Individual
Prefix:
First Name:SORA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 CORPORATE CENTER CT
Mailing Address - Street 2:STE A
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6360
Mailing Address - Country:US
Mailing Address - Phone:678-289-6707
Mailing Address - Fax:850-837-2042
Practice Address - Street 1:330 CORPORATE CENTER CT
Practice Address - Street 2:STE A
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6360
Practice Address - Country:US
Practice Address - Phone:678-289-6707
Practice Address - Fax:850-837-2042
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0135941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice