Provider Demographics
NPI:1326024985
Name:KIM, NAM KWON (DDS)
Entity Type:Individual
Prefix:DR
First Name:NAM
Middle Name:KWON
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36000 SHOEMAKER LANE, STE 1051
Mailing Address - Street 2:
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5054
Mailing Address - Country:US
Mailing Address - Phone:254-287-2705
Mailing Address - Fax:
Practice Address - Street 1:36000 SHOEMAKER LANE, STE 1051
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544-5054
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12574122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist