Provider Demographics
NPI:1619236965
Name:KIM, MIN JUNG (DDS)
Entity Type:Individual
Prefix:
First Name:MIN
Middle Name:JUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 ROSEWICK RD
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-4251
Mailing Address - Country:US
Mailing Address - Phone:301-934-4357
Mailing Address - Fax:
Practice Address - Street 1:124 ROSEWICK RD
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4251
Practice Address - Country:US
Practice Address - Phone:301-934-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014140431223G0001X
NY500568231223G0001X
MD160991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice