Provider Demographics
NPI:1730884560
Name:KIM, DONGSU (DDS)
Entity type:Individual
Prefix:DR
First Name:DONGSU
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E 25TH ST APT 5F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2501
Mailing Address - Country:US
Mailing Address - Phone:804-937-9680
Mailing Address - Fax:
Practice Address - Street 1:1799 N WILLIAMSON BLVD APT 7210
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5309
Practice Address - Country:US
Practice Address - Phone:804-937-9680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN288751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice