Provider Demographics
NPI:1508998782
Name:KIM, MARY ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N COLUMBUS DR APT 2701
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7820
Mailing Address - Country:US
Mailing Address - Phone:312-405-9435
Mailing Address - Fax:
Practice Address - Street 1:233 S WACKER DR
Practice Address - Street 2:LOWER LEVEL 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-6306
Practice Address - Country:US
Practice Address - Phone:312-993-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist