Provider Demographics
NPI:1841430642
Name:KIM, MI LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MI LEE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 FARRELL WAY
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8486
Mailing Address - Country:US
Mailing Address - Phone:720-273-0580
Mailing Address - Fax:
Practice Address - Street 1:6267 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2856
Practice Address - Country:US
Practice Address - Phone:678-826-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO97931223G0001X
GADN0148641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry