Provider Demographics
NPI:1538557533
Name:HAE SOOK KIM DMD LLC
Entity type:Organization
Organization Name:HAE SOOK KIM DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAE SOOK
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:301-290-0001
Mailing Address - Street 1:29795 THREE NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE HALL
Mailing Address - State:MD
Mailing Address - Zip Code:20622-4106
Mailing Address - Country:US
Mailing Address - Phone:301-290-0001
Mailing Address - Fax:301-290-5633
Practice Address - Street 1:29795 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-4106
Practice Address - Country:US
Practice Address - Phone:301-290-0001
Practice Address - Fax:301-290-5633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD025761300Medicaid