Provider Demographics
NPI:1457803710
Name:HANNAH KIM DDS, INC
Entity Type:Organization
Organization Name:HANNAH KIM DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:224-444-8358
Mailing Address - Street 1:895 E GRAND AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7883
Mailing Address - Country:US
Mailing Address - Phone:224-444-8358
Mailing Address - Fax:
Practice Address - Street 1:895 E GRAND AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-7883
Practice Address - Country:US
Practice Address - Phone:224-444-8358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL166805Medicaid
IL166805Medicare PIN