Provider Demographics
NPI:1306110606
Name:KIM, DEMIAN J (DDS)
Entity type:Individual
Prefix:
First Name:DEMIAN
Middle Name:J
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 BOB HOPE DR APT 1606
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-1640
Mailing Address - Country:US
Mailing Address - Phone:646-306-5382
Mailing Address - Fax:
Practice Address - Street 1:811 CHELSEA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4925
Practice Address - Country:US
Practice Address - Phone:915-779-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-04
Last Update Date:2012-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX276121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice