Provider Demographics
NPI:1821475369
Name:KIM, PETER EUSUK (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:EUSUK
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 1:5340 EL PASO DR
Mailing Address - Street 2:SUITE K
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2837
Mailing Address - Country:US
Mailing Address - Phone:915-781-7725
Mailing Address - Fax:915-779-3387
Practice Address - Street 1:4649 LOMA DEL SUR DR
Practice Address - Street 2:APT 3307
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3350
Practice Address - Country:US
Practice Address - Phone:216-526-2174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice