Provider Demographics
NPI:1285846543
Name:KIM, BO NA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:NA
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:25 OLD SNAKE HILL RD
Mailing Address - Street 2:
Mailing Address - City:POUND RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10576-2101
Mailing Address - Country:US
Mailing Address - Phone:917-597-5067
Mailing Address - Fax:914-764-5191
Practice Address - Street 1:150 BROADWAY
Practice Address - Street 2:SUITE 1002
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4381
Practice Address - Country:US
Practice Address - Phone:917-597-5067
Practice Address - Fax:914-764-5191
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0450961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice