Provider Demographics
NPI:1285040998
Name:KIM, KRISTINE EUNSONG (DDS)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:EUNSONG
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 1:3233 SUPERIOR LANE
Mailing Address - Street 2:SUITE B-25
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715
Mailing Address - Country:US
Mailing Address - Phone:301-262-3535
Mailing Address - Fax:301-464-3478
Practice Address - Street 1:3233 SUPERIOR LANE
Practice Address - Street 2:SUITE B-25
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715
Practice Address - Country:US
Practice Address - Phone:301-262-3535
Practice Address - Fax:301-464-3478
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD124971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice