Provider Demographics
NPI:1972925105
Name:KIM, MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:STE 308
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 W 38TH ST
Practice Address - Street 2:SUITE 410
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1163
Practice Address - Country:US
Practice Address - Phone:512-992-1378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340556510Medicaid
TX340556511Medicaid
TX536265YKZJMedicare PIN