Provider Demographics
NPI:1700214293
Name:KIM, SONNY SUNGHUN
Entity Type:Individual
Prefix:DR
First Name:SONNY
Middle Name:SUNGHUN
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11876 SUNRISE VALLEY DRIVE
Mailing Address - Street 2:101
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191
Mailing Address - Country:US
Mailing Address - Phone:703-390-9191
Mailing Address - Fax:703-390-8887
Practice Address - Street 1:11876 SUNRISE VALLEY DRIVE
Practice Address - Street 2:101
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191
Practice Address - Country:US
Practice Address - Phone:703-390-9191
Practice Address - Fax:703-390-8887
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401007832122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice