Provider Demographics
NPI:1376117259
Name:KIM, SARAH SO YOUNG
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:SO YOUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 LONGFELLOW PL APT 1804
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2815
Mailing Address - Country:US
Mailing Address - Phone:484-786-3140
Mailing Address - Fax:
Practice Address - Street 1:50 STANIFORD ST STE 303
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2542
Practice Address - Country:US
Practice Address - Phone:617-648-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-16
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18590371223P0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program