Provider Demographics
NPI:1609394501
Name:KIM, NICK (DMD)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:6649 ENCORE BLVD
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-2889
Mailing Address - Country:US
Mailing Address - Phone:334-549-2714
Mailing Address - Fax:
Practice Address - Street 1:6649 ENCORE BLVD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-2889
Practice Address - Country:US
Practice Address - Phone:334-549-2714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041448122300000X
GADN0160231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist