Provider Demographics
NPI:1467779900
Name:KIM, EUNYOUNG (DMD)
Entity Type:Individual
Prefix:DR
First Name:EUNYOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10522 ROSEHAVEN ST
Mailing Address - Street 2:113
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2860
Mailing Address - Country:US
Mailing Address - Phone:646-246-3869
Mailing Address - Fax:
Practice Address - Street 1:10522 ROSEHAVEN ST
Practice Address - Street 2:113
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2860
Practice Address - Country:US
Practice Address - Phone:646-246-3869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014127011223X0400X
CA576771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics