Provider Demographics
NPI:1225762172
Name:KIM, ODELIA EUNHAE (DDS)
Entity type:Individual
Prefix:
First Name:ODELIA
Middle Name:EUNHAE
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75147-8328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MABANK
Practice Address - State:TX
Practice Address - Zip Code:75147-8328
Practice Address - Country:US
Practice Address - Phone:903-829-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38739122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist