Provider Demographics
NPI:1194401737
Name:KIM, JUNSEOK
Entity type:Individual
Prefix:
First Name:JUNSEOK
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 1:345 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4020
Mailing Address - Country:US
Mailing Address - Phone:212-998-9800
Mailing Address - Fax:
Practice Address - Street 1:4607 DUKE ST UNIT 19A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2505
Practice Address - Country:US
Practice Address - Phone:571-899-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401419165122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program