Provider Demographics
NPI:1528176252
Name:KIM, MI HYUN (DDS)
Entity type:Individual
Prefix:
First Name:MI
Middle Name:HYUN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:HYUN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2765 COLLINS HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043
Mailing Address - Country:US
Mailing Address - Phone:770-630-5730
Mailing Address - Fax:
Practice Address - Street 1:2765 COLLINS HILL RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043
Practice Address - Country:US
Practice Address - Phone:770-630-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC78231223G0001X
GADN0136421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903232Medicaid
9025YOtherBLUE CROSS BLUE SHIELD NC