Provider Demographics
NPI:1467783092
Name:HJ KIM DDS, PA
Entity Type:Organization
Organization Name:HJ KIM DDS, PA
Other - Org Name:SMART DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEEJUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-740-1484
Mailing Address - Street 1:9501 OLD ANNAPOLIS RD
Mailing Address - Street 2:STE. 200 A
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6314
Mailing Address - Country:US
Mailing Address - Phone:410-740-1484
Mailing Address - Fax:410-740-1486
Practice Address - Street 1:9501 OLD ANNAPOLIS RD
Practice Address - Street 2:STE. 200 A
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-6314
Practice Address - Country:US
Practice Address - Phone:410-740-1484
Practice Address - Fax:410-740-1486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13733122300000X, 1223D0001X, 1223G0001X, 1223X0400X
126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No126800000XDental ProvidersDental AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD028082800Medicaid