Provider Demographics
NPI:1235813841
Name:KIM, MICHELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1 NASSAU ST APT 907
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1554
Mailing Address - Country:US
Mailing Address - Phone:617-631-7380
Mailing Address - Fax:
Practice Address - Street 1:180 LINCOLN ST STE 2A
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-2400
Practice Address - Country:US
Practice Address - Phone:617-338-0833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859882122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist