Provider Demographics
NPI:1992359954
Name:KIM, MOOCHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MOOCHAN
Middle Name:
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 1:40 BENNETT RD UNIT 229
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3268
Mailing Address - Country:US
Mailing Address - Phone:917-421-0997
Mailing Address - Fax:
Practice Address - Street 1:4546 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-6403
Practice Address - Country:US
Practice Address - Phone:718-948-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02925300122300000X
IL019.032304122300000X
NY062241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist