Provider Demographics
NPI:1659385367
Name:KIM, MICHAEL HANSOO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:HANSOO
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21001 SYCOLIN RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4073
Mailing Address - Country:US
Mailing Address - Phone:703-723-4224
Mailing Address - Fax:
Practice Address - Street 1:21001 SYCOLIN RD
Practice Address - Street 2:SUITE 240
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4073
Practice Address - Country:US
Practice Address - Phone:703-723-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018597122300000X
VA0401413573122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4631948Medicaid
MI4631957Medicaid