Provider Demographics
NPI:1376981258
Name:KIM, MIJUNG
Entity Type:Individual
Prefix:
First Name:MIJUNG
Middle Name:
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 1:85 WESTERN AVE
Mailing Address - Street 2:#3
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2423
Mailing Address - Country:US
Mailing Address - Phone:207-408-0479
Mailing Address - Fax:207-541-9304
Practice Address - Street 1:85 WESTERN AVE
Practice Address - Street 2:#3
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2423
Practice Address - Country:US
Practice Address - Phone:207-408-0479
Practice Address - Fax:207-541-9304
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN43151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice