Provider Demographics
NPI:1477907459
Name:KIM, SE JONG (DMD, MS)
Entity Type:Individual
Prefix:
First Name:SE JONG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1107 NELSON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2031
Mailing Address - Country:US
Mailing Address - Phone:412-651-8614
Mailing Address - Fax:
Practice Address - Street 1:1107 NELSON ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2031
Practice Address - Country:US
Practice Address - Phone:301-424-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-16
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD158781223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics