Provider Demographics
NPI:1467892943
Name:KIM, STELLA KIM (DDS)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:KIM
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JI
Other - Middle Name:WON
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:516 ORONOCO ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2306
Mailing Address - Country:US
Mailing Address - Phone:703-549-1960
Mailing Address - Fax:
Practice Address - Street 1:516 ORONOCO ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2306
Practice Address - Country:US
Practice Address - Phone:703-549-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014143351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00384309Medicaid