Provider Demographics
NPI:1942618806
Name:KIM, SAMUEL (DMD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
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 1:2101 AVENEL BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-3946
Mailing Address - Country:US
Mailing Address - Phone:267-342-4409
Mailing Address - Fax:
Practice Address - Street 1:725 RIVER RD
Practice Address - Street 2:53
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1171
Practice Address - Country:US
Practice Address - Phone:201-943-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02578100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist