Provider Demographics
NPI:1225561137
Name:KIM, SUE YOUN
Entity Type:Individual
Prefix:
First Name:SUE YOUN
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 1:841 NONHYEON-RO
Mailing Address - Street 2:ROOM #410
Mailing Address - City:SEOUL
Mailing Address - State:GANGNAMKU
Mailing Address - Zip Code:06031
Mailing Address - Country:KR
Mailing Address - Phone:822-594-2850
Mailing Address - Fax:8223-442-2855
Practice Address - Street 1:841 NONHYEON-RO
Practice Address - Street 2:ROOM #410
Practice Address - City:SEOUL
Practice Address - State:GANGNAMKU
Practice Address - Zip Code:06031
Practice Address - Country:KR
Practice Address - Phone:822-594-2850
Practice Address - Fax:8223-442-2855
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD149931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice