Provider Demographics
NPI:1497233761
Name:KIM, NICKOLAS JI (DDS)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:JI
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 CROYDON PLACE
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062
Mailing Address - Country:US
Mailing Address - Phone:702-505-1257
Mailing Address - Fax:
Practice Address - Street 1:8301 S HOLLAND RD STE B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-1303
Practice Address - Country:US
Practice Address - Phone:312-274-4524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0318131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice