Provider Demographics
NPI:1821541335
Name:KIM, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:618TH DENTAL COMPANY AS USA DENTAC
Practice Address - Street 2:UNIT 15652
Practice Address - City:SEOUL
Practice Address - State:SEOUL
Practice Address - Zip Code:96205 5652
Practice Address - Country:KR
Practice Address - Phone:011-822-7917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS100248122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist