Provider Demographics
NPI:1487820650
Name:KIM, HAE SOOK (D M D)
Entity Type:Individual
Prefix:DR
First Name:HAE SOOK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:D M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29795 THREE NOTCH ROAD
Mailing Address - Street 2:P O BOX 653
Mailing Address - City:CHARLOTTE HALL
Mailing Address - State:MD
Mailing Address - Zip Code:20622
Mailing Address - Country:US
Mailing Address - Phone:301-290-0001
Mailing Address - Fax:301-290-5633
Practice Address - Street 1:29795 THREE NOTCH ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622
Practice Address - Country:US
Practice Address - Phone:301-290-0001
Practice Address - Fax:301-290-5633
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD139311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice