Provider Demographics
NPI:1760816607
Name:KIM, KELLY HEEJUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:HEEJUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15517 BRYANT PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-1711
Mailing Address - Country:US
Mailing Address - Phone:682-308-4015
Mailing Address - Fax:
Practice Address - Street 1:26742 E. UNIVERSITY DR.
Practice Address - Street 2:BUILDING 200, SUITE 220
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227
Practice Address - Country:US
Practice Address - Phone:972-845-1234
Practice Address - Fax:972-845-1212
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX325191019Medicaid