Provider Demographics
NPI:1417007584
Name:KIM, DAVID TAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TAE
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:TAE
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:16114 NORTHERN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1633
Mailing Address - Country:US
Mailing Address - Phone:718-762-7006
Mailing Address - Fax:718-445-4518
Practice Address - Street 1:16114 NORTHERN BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1633
Practice Address - Country:US
Practice Address - Phone:718-762-7006
Practice Address - Fax:718-445-4518
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040283-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice