Provider Demographics
NPI:1336215979
Name:KIM, SUSAN (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
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 1:3701 KIRBY DR
Mailing Address - Street 2:SUITE 550
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-3900
Mailing Address - Country:US
Mailing Address - Phone:512-892-5988
Mailing Address - Fax:512-892-4064
Practice Address - Street 1:4534 W GATE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1485
Practice Address - Country:US
Practice Address - Phone:512-892-5988
Practice Address - Fax:512-892-4064
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice