Provider Demographics
NPI:1891731204
Name:KIM, JOHN MARION (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARION
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 1:3102 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8609
Mailing Address - Country:US
Mailing Address - Phone:269-429-7122
Mailing Address - Fax:269-429-6410
Practice Address - Street 1:3102 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8609
Practice Address - Country:US
Practice Address - Phone:269-429-7122
Practice Address - Fax:269-429-6410
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0143471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2983370Medicaid
MI5116012Medicare ID - Type Unspecified
MIU05429Medicare UPIN