Provider Demographics
NPI:1912076738
Name:KIM, SONGHYON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SONGHYON
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 1:502 S 1040 E APT 131
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3381
Mailing Address - Country:US
Mailing Address - Phone:801-633-1919
Mailing Address - Fax:
Practice Address - Street 1:2961 W MAPLE LOOP DR STE 110
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5717
Practice Address - Country:US
Practice Address - Phone:801-766-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025304122300000X
UT265201-9923122300000X
ORD10160122300000X
UT265201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1912076738Medicaid