Provider Demographics
NPI:1659444099
Name:KIM, MIN JUNG (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIN JUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MINJUNG
Other - Middle Name:
Other - Last Name:YOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:340 MAPLE STREET
Mailing Address - Street 2:#210
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752
Mailing Address - Country:US
Mailing Address - Phone:508-480-9299
Mailing Address - Fax:508-480-9979
Practice Address - Street 1:340 MAPLE STREET
Practice Address - Street 2:#210
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752
Practice Address - Country:US
Practice Address - Phone:508-480-9299
Practice Address - Fax:508-480-9979
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN202651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9763210Medicaid