Provider Demographics
NPI:1720489149
Name:KIM, HEE SOO
Entity Type:Individual
Prefix:DR
First Name:HEE SOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 WASHINGTON BLVD
Mailing Address - Street 2:APT 1008S
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2451
Mailing Address - Country:US
Mailing Address - Phone:917-603-0675
Mailing Address - Fax:
Practice Address - Street 1:666 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3775
Practice Address - Country:US
Practice Address - Phone:203-889-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT112551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice