Provider Demographics
NPI:1386165736
Name:KIM, SUSUN THERESA (DMD)
Entity type:Individual
Prefix:DR
First Name:SUSUN
Middle Name:THERESA
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
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Other - Credentials:
Mailing Address - Street 1:59 DG AF POSTGRADUATE DENTAL SCHOOL
Mailing Address - Street 2:2133 KLINKER STREET, BUILDING 3352
Mailing Address - City:JBSA-LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5313
Mailing Address - Country:US
Mailing Address - Phone:210-228-3838
Mailing Address - Fax:
Practice Address - Street 1:4175 SOUTH ALAMO AVENUE
Practice Address - Street 2:355 MDG
Practice Address - City:DAVIS-MONTHAN AFB
Practice Address - State:AZ
Practice Address - Zip Code:85707-4406
Practice Address - Country:US
Practice Address - Phone:520-228-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ22DI027577001223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics