Provider Demographics
NPI:1316509367
Name:KIM, GRACE MISUN (DMD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:MISUN
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 S HUNTINGTON AVE APT 432
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4851
Mailing Address - Country:US
Mailing Address - Phone:404-488-3283
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-30
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858542122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist