Provider Demographics
NPI:1811916877
Name:KIM, PETER GEUNTAE (DDS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:GEUNTAE
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:GEUNTAE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:17 KATHLEEN DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-5808
Mailing Address - Country:US
Mailing Address - Phone:516-993-9691
Mailing Address - Fax:718-224-5587
Practice Address - Street 1:4719 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3333
Practice Address - Country:US
Practice Address - Phone:718-224-5576
Practice Address - Fax:718-224-5587
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0471521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02512985Medicaid