Provider Demographics
NPI:1417353400
Name:KIM, PETER J (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
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 1:7 STUART CT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4237
Mailing Address - Country:US
Mailing Address - Phone:631-355-4180
Mailing Address - Fax:
Practice Address - Street 1:728 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW SQUARE
Practice Address - State:NY
Practice Address - Zip Code:10977-8916
Practice Address - Country:US
Practice Address - Phone:845-354-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0581421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice