Provider Demographics
NPI:1801543293
Name:KIM, DAEWOONG (DDS)
Entity type:Individual
Prefix:
First Name:DAEWOONG
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 1:261 CHEONSURO SUSUNGGU
Mailing Address - Street 2:CASTLE GOLD PARK APT 1416/901
Mailing Address - City:DAEGU
Mailing Address - State:NOT APPLICABLE
Mailing Address - Zip Code:42114
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ # 154
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3198
Practice Address - Country:US
Practice Address - Phone:718-240-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT123891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice