Provider Demographics
NPI:1427157940
Name:KIM, KYUNG HYUN (DDS)
Entity type:Individual
Prefix:
First Name:KYUNG
Middle Name:HYUN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BARSTOW RD # P23
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3501
Mailing Address - Country:US
Mailing Address - Phone:516-466-8744
Mailing Address - Fax:516-829-3650
Practice Address - Street 1:1 BARSTOW RD # P23
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3501
Practice Address - Country:US
Practice Address - Phone:516-466-8744
Practice Address - Fax:516-829-3650
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5653015122300000X
NY0532321223G0001X
NY053232-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33782800Medicaid
NY02832768Medicaid