Provider Demographics
NPI:1841627452
Name:KIM, KI YOUNG (DMD)
Entity type:Individual
Prefix:
First Name:KI YOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 HUDSON TER
Mailing Address - Street 2:#G107
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2902
Mailing Address - Country:US
Mailing Address - Phone:201-816-8000
Mailing Address - Fax:201-816-9000
Practice Address - Street 1:464 HUDSON TER
Practice Address - Street 2:#G107
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2902
Practice Address - Country:US
Practice Address - Phone:201-816-8000
Practice Address - Fax:201-816-9000
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-28
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025476001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice