Provider Demographics
NPI:1336207554
Name:KIM, DONGSUP (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONGSUP
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 1:9901 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1904
Mailing Address - Country:US
Mailing Address - Phone:703-323-4024
Mailing Address - Fax:703-323-4252
Practice Address - Street 1:9901 BRADDOCK RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-1904
Practice Address - Country:US
Practice Address - Phone:703-323-4024
Practice Address - Fax:703-323-4252
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010064681223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health