Provider Demographics
NPI:1598287484
Name:KIM, ALEXANDER Y (DDS)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:Y
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 1:3306 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-4203
Mailing Address - Country:US
Mailing Address - Phone:847-636-7612
Mailing Address - Fax:
Practice Address - Street 1:1135 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-5313
Practice Address - Country:US
Practice Address - Phone:512-240-6623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX366161223G0001X
ORD10680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice