Provider Demographics
NPI:1831680750
Name:KIM, KEVIN MINSUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MINSUNG
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 1:1717 OLYMPIA WAY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3929
Mailing Address - Country:US
Mailing Address - Phone:360-636-1900
Mailing Address - Fax:
Practice Address - Street 1:1717 OLYMPIA WAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3929
Practice Address - Country:US
Practice Address - Phone:360-636-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-26
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE610346971223G0001X, 1223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist