Provider Demographics
NPI:1912026865
Name:KIM, DONG-IL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONG-IL
Middle Name:
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 1:295 BLUEJAY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-4607
Mailing Address - Country:US
Mailing Address - Phone:614-985-5724
Mailing Address - Fax:
Practice Address - Street 1:1495 MORSE RD
Practice Address - Street 2:# 305
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-6478
Practice Address - Country:US
Practice Address - Phone:614-263-8858
Practice Address - Fax:614-263-8859
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-022494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist