Provider Demographics
NPI:1679694293
Name:KIM, DONG WON (DMD)
Entity Type:Individual
Prefix:DR
First Name:DONG
Middle Name:WON
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 1:3600 MYSTIC VALLEY PKWY
Mailing Address - Street 2:APT # 709
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5733
Mailing Address - Country:US
Mailing Address - Phone:781-393-4830
Mailing Address - Fax:
Practice Address - Street 1:133 MARKET ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1808
Practice Address - Country:US
Practice Address - Phone:978-458-1179
Practice Address - Fax:978-805-1415
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2023-01-26
Deactivation Date:2019-11-07
Deactivation Code:
Reactivation Date:2019-11-19
Provider Licenses
StateLicense IDTaxonomies
MA21536122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0207110Medicaid