Provider Demographics
NPI:1720240294
Name:KIM, MATTHEW PETER (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PETER
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 1:14535 JOHN MARSHALL HWY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-4023
Mailing Address - Country:US
Mailing Address - Phone:703-753-2252
Mailing Address - Fax:703-753-9832
Practice Address - Street 1:14535 JOHN MARSHALL HWY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-4023
Practice Address - Country:US
Practice Address - Phone:703-753-2252
Practice Address - Fax:703-753-9832
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014121921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice