Provider Demographics
NPI:1306938709
Name:KIM, MICHAEL I (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:I
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 1:10033 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5799
Mailing Address - Country:US
Mailing Address - Phone:262-241-5558
Mailing Address - Fax:252-241-5545
Practice Address - Street 1:10033 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5799
Practice Address - Country:US
Practice Address - Phone:262-241-5558
Practice Address - Fax:252-241-5545
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3705122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist