Provider Demographics
NPI:1104987221
Name:KIM, YUNSUP (DDS)
Entity type:Individual
Prefix:DR
First Name:YUNSUP
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 1:2 EMERALD TER
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2321
Mailing Address - Country:US
Mailing Address - Phone:618-233-1707
Mailing Address - Fax:618-233-1769
Practice Address - Street 1:2 EMERALD TER
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2321
Practice Address - Country:US
Practice Address - Phone:618-233-1707
Practice Address - Fax:618-233-1769
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL007253Medicaid