Provider Demographics
NPI:1568080414
Name:KIM, SHAWN J (DMD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:J
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 1:1441 U ST NW APT 205
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-3518
Mailing Address - Country:US
Mailing Address - Phone:973-349-5954
Mailing Address - Fax:
Practice Address - Street 1:5500 COLUMBIA PIKE STE B
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-5867
Practice Address - Country:US
Practice Address - Phone:703-575-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN2000225122300000X
VA04014173531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Multi-Specialty