Provider Demographics
NPI:1699429258
Name:KIM, DAVID TAE (LAC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:TAE
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:210 WHITEMAN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6943
Mailing Address - Country:US
Mailing Address - Phone:862-246-6885
Mailing Address - Fax:
Practice Address - Street 1:210 WHITEMAN ST STE 105
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6943
Practice Address - Country:US
Practice Address - Phone:862-246-6885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007062171100000X
NJ25MZ00157700171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist