Provider Demographics
NPI:1932497500
Name:KIM, SUNG SOO (DDS)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:SOO
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 1:1667 COCHRANE CIR BLDG 7495
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4603
Mailing Address - Country:US
Mailing Address - Phone:719-526-5537
Mailing Address - Fax:
Practice Address - Street 1:4TH AND INNER LOOP ROAD
Practice Address - Street 2:BLDG 171
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014130021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401413002OtherDENTIST LICENSE