Provider Demographics
NPI:1497150668
Name:KIM, SUNG MIN
Entity Type:Individual
Prefix:
First Name:SUNG MIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 FIR CT
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07648-2010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HANSHAW RD STE 14
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1589
Practice Address - Country:US
Practice Address - Phone:607-257-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0584151223G0001X
NJ22DI025996001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice