Provider Demographics
NPI:1619201316
Name:KIM, YEONJOO (DMD)
Entity Type:Individual
Prefix:
First Name:YEONJOO
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 GRANVILLE DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7975
Mailing Address - Country:US
Mailing Address - Phone:954-682-0666
Mailing Address - Fax:
Practice Address - Street 1:4533 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6013
Practice Address - Country:US
Practice Address - Phone:706-660-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0139911223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry