Provider Demographics
NPI:1285925669
Name:KIM, WAN
Entity type:Individual
Prefix:
First Name:WAN
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 1:1120 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:#203
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2013
Mailing Address - Country:US
Mailing Address - Phone:770-904-7005
Mailing Address - Fax:
Practice Address - Street 1:1120 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:#203
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2013
Practice Address - Country:US
Practice Address - Phone:770-904-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant