Provider Demographics
NPI:1790920049
Name:KIM, JOO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOO
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 1:3366 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3770
Mailing Address - Country:US
Mailing Address - Phone:516-826-4949
Mailing Address - Fax:
Practice Address - Street 1:3366 PARK AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3770
Practice Address - Country:US
Practice Address - Phone:646-784-2703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2023-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02390000122300000X
NY054830-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist