Provider Demographics
NPI:1629119300
Name:KIM, LILA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LILA
Middle Name:
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 1:9010 LORTON STATION BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4794
Mailing Address - Country:US
Mailing Address - Phone:703-436-4633
Mailing Address - Fax:
Practice Address - Street 1:9010 LORTON STATION BLVD STE 140
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4794
Practice Address - Country:US
Practice Address - Phone:703-436-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014183531223S0112X
MD169061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02290077Medicaid