Provider Demographics
NPI:1568624815
Name:KIM, JUNG-WAN MARTIN (BSC, DMD)
Entity Type:Individual
Prefix:DR
First Name:JUNG-WAN MARTIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:BSC, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 DELAWARE STREET SE
Mailing Address - Street 2:7-360 MOOS HEALTH SCIENCE TOWER
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-6177
Mailing Address - Fax:612-626-2652
Practice Address - Street 1:515 DELAWARE STREET SE
Practice Address - Street 2:7-360 MOOS HEALTH SCIENCE TOWER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-6177
Practice Address - Fax:612-626-2652
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist