Provider Demographics
NPI:1841612744
Name:KIM, YOUNGDAE (DMD)
Entity Type:Individual
Prefix:DR
First Name:YOUNGDAE
Middle Name:
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 1:5417D BACKLICK RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-3915
Mailing Address - Country:US
Mailing Address - Phone:703-988-3386
Mailing Address - Fax:703-988-3389
Practice Address - Street 1:5417D BACKLICK RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3915
Practice Address - Country:US
Practice Address - Phone:703-988-3386
Practice Address - Fax:703-988-3389
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0398411223G0001X
VA04014151451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program