Provider Demographics
NPI:1801524608
Name:KIM, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3159 IRON CYN
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3159 IRON CYN
Practice Address - Street 2:
Practice Address - City:BULVERDE
Practice Address - State:TX
Practice Address - Zip Code:78163-5503
Practice Address - Country:US
Practice Address - Phone:210-264-2962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX381971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice