Provider Demographics
NPI:1215490495
Name:KIM, BRYAN S (DMD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:S
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 1:2866 S UNIVERSITY DR APT 5307
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1405
Mailing Address - Country:US
Mailing Address - Phone:310-634-5702
Mailing Address - Fax:
Practice Address - Street 1:3830 PARSONS BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5841
Practice Address - Country:US
Practice Address - Phone:310-634-5702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0613811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice