Provider Demographics
NPI:1568153161
Name:KIM HENDERSON KIDS DENTISTRY PC
Entity Type:Organization
Organization Name:KIM HENDERSON KIDS DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYUNG
Authorized Official - Middle Name:M
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-558-8543
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:382 W LAKE MEAD PKWY STE 130
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7292
Practice Address - Country:US
Practice Address - Phone:703-558-8543
Practice Address - Fax:702-673-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty