Provider Demographics
NPI:1891127106
Name:KIM, SOYOUNG (DMD)
Entity Type:Individual
Prefix:
First Name:SOYOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CORTLAND WAY
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:MA
Mailing Address - Zip Code:01519-1093
Mailing Address - Country:US
Mailing Address - Phone:508-395-7833
Mailing Address - Fax:
Practice Address - Street 1:55 SACK BLVD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3325
Practice Address - Country:US
Practice Address - Phone:978-466-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN03191122300000X
MADN1856371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist