Provider Demographics
NPI:1740604107
Name:KIM, JEONGHYEON
Entity Type:Individual
Prefix:DR
First Name:JEONGHYEON
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8214 GOLDEN OAK CIR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8504
Mailing Address - Country:US
Mailing Address - Phone:716-829-2862
Mailing Address - Fax:716-829-2440
Practice Address - Street 1:215 SQUIRE HALL
Practice Address - Street 2:3435 MAIN ST
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-8006
Practice Address - Country:US
Practice Address - Phone:716-829-2862
Practice Address - Fax:716-829-2440
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000044122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist