Provider Demographics
NPI:1720218910
Name:KIM, JOHN Y
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:Y
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:921 FANSHAWE ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-4801
Mailing Address - Country:US
Mailing Address - Phone:215-779-6957
Mailing Address - Fax:215-695-0622
Practice Address - Street 1:1936 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19111-3800
Practice Address - Country:US
Practice Address - Phone:215-728-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024115L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist