Provider Demographics
NPI:1104062009
Name:KIM, RICHARD JAY (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAY
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 1:858 CLUB RIDGE TER
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2746
Mailing Address - Country:US
Mailing Address - Phone:804-530-0245
Mailing Address - Fax:804-530-0245
Practice Address - Street 1:400 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 800
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5980
Practice Address - Country:US
Practice Address - Phone:678-904-5665
Practice Address - Fax:678-904-5665
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014123291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice