Provider Demographics
NPI:1609311166
Name:KIM, DWIGHT
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7535 LITTLE RIVER TPKE
Mailing Address - Street 2:103A
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2937
Mailing Address - Country:US
Mailing Address - Phone:703-595-2125
Mailing Address - Fax:888-276-6354
Practice Address - Street 1:7535 LITTLE RIVER TPKE
Practice Address - Street 2:103A
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2937
Practice Address - Country:US
Practice Address - Phone:703-595-2125
Practice Address - Fax:888-276-6354
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000814171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist