Provider Demographics
NPI:1710329529
Name:KIM, KITAE (DDS)
Entity Type:Individual
Prefix:
First Name:KITAE
Middle Name:
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 1:6825 E HAMPDEN AVE
Mailing Address - Street 2:#101
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-3029
Mailing Address - Country:US
Mailing Address - Phone:303-756-3289
Mailing Address - Fax:
Practice Address - Street 1:6825 E HAMPDEN AVE
Practice Address - Street 2:#101
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-3029
Practice Address - Country:US
Practice Address - Phone:303-756-3289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202263122300000X
CODEN.002022631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist