Provider Demographics
NPI:1962856070
Name:KIM, DOUGLAS WILLIAM (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:NJ
Mailing Address - Zip Code:07620-0663
Mailing Address - Country:US
Mailing Address - Phone:201-245-4362
Mailing Address - Fax:
Practice Address - Street 1:570 PIERMONT RD STE C1
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-3100
Practice Address - Country:US
Practice Address - Phone:201-666-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027683001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics