Provider Demographics
NPI:1912107194
Name:KIM, MIN C (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIN
Middle Name:C
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4270 GORGAS CIRCLE
Mailing Address - Street 2:ATTN: ROBERTA DRISKILL
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2639
Mailing Address - Country:US
Mailing Address - Phone:210-221-6326
Mailing Address - Fax:
Practice Address - Street 1:3145 GARDEN AVE STE 1278
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7719
Practice Address - Country:US
Practice Address - Phone:210-808-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0517051223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice