Provider Demographics
NPI:1902967599
Name:KIM, SOOJIN (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:SOOJIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618TH DENTAL COMPANY AS
Mailing Address - Street 2:UNIT 15652, DENTAL CLINIC 3
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-0652
Mailing Address - Country:US
Mailing Address - Phone:8227-916-5221
Mailing Address - Fax:0
Practice Address - Street 1:618TH DENTAL COMPANY AS
Practice Address - Street 2:UNIT 15652 DENTAL CLINIC 3
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-0652
Practice Address - Country:US
Practice Address - Phone:0118227-916-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000101011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics