Provider Demographics
NPI:1205210929
Name:KIM, KENNETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
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 1:20212 EVA ST.
Mailing Address - Street 2:#160
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356
Mailing Address - Country:US
Mailing Address - Phone:617-281-3190
Mailing Address - Fax:
Practice Address - Street 1:6519 FM 1488, WESTWOOD VILLAGE,
Practice Address - Street 2:#505
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354
Practice Address - Country:US
Practice Address - Phone:281-305-8835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice