Provider Demographics
NPI:1407598600
Name:KIM, KEVIN (DMD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HAMMOND POND PKWY
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 WASHINGTON ST STE 222
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-4009
Practice Address - Country:US
Practice Address - Phone:781-451-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859373122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist