Provider Demographics
NPI:1922140425
Name:KIM, KYUNG IL (DDS)
Entity Type:Individual
Prefix:
First Name:KYUNG
Middle Name:IL
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 1:214 20 45 ROAD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3338
Mailing Address - Country:US
Mailing Address - Phone:718-229-6202
Mailing Address - Fax:718-229-1655
Practice Address - Street 1:214 20 45 ROAD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3338
Practice Address - Country:US
Practice Address - Phone:718-229-6202
Practice Address - Fax:718-229-1655
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0424951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0089160Medicaid