Provider Demographics
NPI:1568483717
Name:MICHELSON, KIM JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:JAMES
Last Name:MICHELSON
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 1:1480 N 8000 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1480 N 8000 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3961
Practice Address - Country:US
Practice Address - Phone:801-522-7135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT143483-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice