Provider Demographics
NPI:1336564699
Name:KIM, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16114 NORTHERN BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1633
Mailing Address - Country:US
Mailing Address - Phone:718-762-7006
Mailing Address - Fax:
Practice Address - Street 1:16114 NORTHERN BLVD FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1633
Practice Address - Country:US
Practice Address - Phone:718-762-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY057935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program