Provider Demographics
NPI:1841501442
Name:KIM, HYEONG CHAN (DDS, PHD)
Entity type:Individual
Prefix:
First Name:HYEONG
Middle Name:CHAN
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4238 79TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3057
Mailing Address - Country:US
Mailing Address - Phone:917-602-7420
Mailing Address - Fax:
Practice Address - Street 1:4238 79TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-3057
Practice Address - Country:US
Practice Address - Phone:917-602-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0558811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice