Provider Demographics
NPI:1215203724
Name:KIM, CHAN-KYU (DMD)
Entity Type:Individual
Prefix:MR
First Name:CHAN-KYU
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:C
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:709 BERGEN BLVD.
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657
Mailing Address - Country:US
Mailing Address - Phone:201-313-0500
Mailing Address - Fax:201-313-0500
Practice Address - Street 1:709 BERGEN BLVD.
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657
Practice Address - Country:US
Practice Address - Phone:201-313-0500
Practice Address - Fax:201-313-0500
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01625400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist