Provider Demographics
NPI:1184165516
Name:KIM, MARY (DMD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PRESTWICK LN
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-6231
Mailing Address - Country:US
Mailing Address - Phone:847-668-0125
Mailing Address - Fax:
Practice Address - Street 1:2424 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4100
Practice Address - Country:US
Practice Address - Phone:773-761-0300
Practice Address - Fax:773-761-0300
Is Sole Proprietor?:No
Enumeration Date:2017-03-18
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031189122300000X
TX34965122300000X
390200000X
GADN1225441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program