Provider Demographics
NPI:1336371806
Name:KIM, DAE HO (DDS)
Entity Type:Individual
Prefix:
First Name:DAE
Middle Name:HO
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 1:618TH THEATER DENTAL COMMAND
Mailing Address - Street 2:UNIT#15652
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5652
Mailing Address - Country:US
Mailing Address - Phone:027-916-8803
Mailing Address - Fax:
Practice Address - Street 1:618TH THEATER DENTAL COMMAND
Practice Address - Street 2:UNIT#15652
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-5652
Practice Address - Country:US
Practice Address - Phone:027-916-8803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014125961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice