Provider Demographics
NPI:1346811296
Name:KIM, SI YUL (DMD)
Entity Type:Individual
Prefix:
First Name:SI YUL
Middle Name:
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 1:2231 RIVERVIEW AVE APT 231
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-8719
Mailing Address - Country:US
Mailing Address - Phone:201-983-3856
Mailing Address - Fax:
Practice Address - Street 1:54 MAIN ST STE F
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-3009
Practice Address - Country:US
Practice Address - Phone:203-790-0111
Practice Address - Fax:203-797-0822
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT131981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice