Provider Demographics
NPI:1356717987
Name:KIM, JUAN (DDS)
Entity type:Individual
Prefix:
First Name:JUAN
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 1:2101 CHARLOTTE ST STE 310
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2727
Mailing Address - Country:US
Mailing Address - Phone:816-404-0500
Mailing Address - Fax:
Practice Address - Street 1:2101 CHARLOTTE ST STE 310
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2727
Practice Address - Country:US
Practice Address - Phone:816-404-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10311122300000X
MO20180117061223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice