Provider Demographics
NPI:1356487003
Name:KIM, DAVID DAEWON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DAEWON
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 1:455 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3330
Mailing Address - Country:US
Mailing Address - Phone:410-939-3890
Mailing Address - Fax:410-939-7671
Practice Address - Street 1:455 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3330
Practice Address - Country:US
Practice Address - Phone:410-939-3890
Practice Address - Fax:410-939-7671
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD108391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD081934400Medicaid