Provider Demographics
NPI:1821415852
Name:KIM, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
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 1:830 W END CT
Mailing Address - Street 2:SUITE 175
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1365
Mailing Address - Country:US
Mailing Address - Phone:847-367-4920
Mailing Address - Fax:847-367-4943
Practice Address - Street 1:830 W END CT
Practice Address - Street 2:SUITE 175
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1365
Practice Address - Country:US
Practice Address - Phone:847-367-4920
Practice Address - Fax:847-367-4943
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029341122300000X
IL0210025131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist