Provider Demographics
NPI:1104354331
Name:KIM, DOOHAK
Entity type:Individual
Prefix:
First Name:DOOHAK
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1886
Mailing Address - Country:US
Mailing Address - Phone:248-917-2475
Mailing Address - Fax:
Practice Address - Street 1:205 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1886
Practice Address - Country:US
Practice Address - Phone:248-917-2475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist