Provider Demographics
NPI:1639358211
Name:KIM, KING (DMD)
Entity Type:Individual
Prefix:DR
First Name:KING
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S PINE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3189
Mailing Address - Country:US
Mailing Address - Phone:321-725-5377
Mailing Address - Fax:321-951-3393
Practice Address - Street 1:1325 S PINE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3189
Practice Address - Country:US
Practice Address - Phone:321-725-5377
Practice Address - Fax:321-951-3393
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN1822281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL63A10OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL63A10OtherBLUE CROSS BLUE SHIELD OF FLORIDA