Provider Demographics
NPI:1154943785
Name:KIM, KYEONG HWAN (DMD)
Entity type:Individual
Prefix:DR
First Name:KYEONG HWAN
Middle Name:
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 1:4221 OLD DENTON RD APT 6201
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-2332
Mailing Address - Country:US
Mailing Address - Phone:567-408-9815
Mailing Address - Fax:
Practice Address - Street 1:5757 WARREN PKWY STE 220
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4207
Practice Address - Country:US
Practice Address - Phone:567-408-9815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026136122300000X
TX388291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist