Provider Demographics
NPI:1306191051
Name:KIM, ROY JUN (DMD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:JUN
Last Name:KIM
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 1:1440 RIVERDALE ST
Mailing Address - Street 2:APT. C3
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-4642
Mailing Address - Country:US
Mailing Address - Phone:714-615-7869
Mailing Address - Fax:
Practice Address - Street 1:555 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-4101
Practice Address - Country:US
Practice Address - Phone:413-736-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856073122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist