Provider Demographics
NPI:1396943379
Name:KIM, MATTHEW MIN KYU (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MIN KYU
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 1:121 TOWNE ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-5930
Mailing Address - Country:US
Mailing Address - Phone:917-748-7355
Mailing Address - Fax:
Practice Address - Street 1:121 TOWNE ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-5930
Practice Address - Country:US
Practice Address - Phone:917-748-7355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054305122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03168458Medicaid