Provider Demographics
NPI:1528449873
Name:KIM, MIN SOO (DMD)
Entity type:Individual
Prefix:DR
First Name:MIN
Middle Name:SOO
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N DIRKSEN PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-1407
Mailing Address - Country:US
Mailing Address - Phone:217-814-0407
Mailing Address - Fax:
Practice Address - Street 1:4260 WESTBROOK DR STE 105
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-8136
Practice Address - Country:US
Practice Address - Phone:630-851-0450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012332A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist