Provider Demographics
NPI:1437275047
Name:KIM, MITCHELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
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 1:3610 SHIRE BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2241
Mailing Address - Country:US
Mailing Address - Phone:972-578-6633
Mailing Address - Fax:972-578-6637
Practice Address - Street 1:3610 SHIRE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2241
Practice Address - Country:US
Practice Address - Phone:972-578-6633
Practice Address - Fax:972-578-6637
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice