Provider Demographics
NPI:1295810554
Name:KIM, MICHAEL ETHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ETHAN
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:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-0455
Mailing Address - Country:US
Mailing Address - Phone:201-575-1153
Mailing Address - Fax:
Practice Address - Street 1:5322 FRANCIS LEWIS BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-1633
Practice Address - Country:US
Practice Address - Phone:201-575-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0530991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice