Provider Demographics
NPI:1235650664
Name:LIM, KEN MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:MICHAEL
Last Name:LIM
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 1:4025 DUVAL RD APT 2536
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3467
Mailing Address - Country:US
Mailing Address - Phone:806-438-9080
Mailing Address - Fax:
Practice Address - Street 1:12920 W PARMER LN STE 101
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7635
Practice Address - Country:US
Practice Address - Phone:512-410-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX335171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice