Provider Demographics
NPI:1770660664
Name:KIM, MYUNG DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:MYUNG
Middle Name:DAVID
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 W TABOR RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141
Mailing Address - Country:US
Mailing Address - Phone:215-224-7757
Mailing Address - Fax:215-424-8103
Practice Address - Street 1:1335 W TABOR RD
Practice Address - Street 2:SUITE 307
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141
Practice Address - Country:US
Practice Address - Phone:215-224-7757
Practice Address - Fax:215-424-8103
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAD0285581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR061742Medicare ID - Type UnspecifiedGROUP #
T27903Medicare UPIN