Provider Demographics
NPI:1912633868
Name:KIM, SI YEON (DDS)
Entity type:Individual
Prefix:DR
First Name:SI YEON
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 MDG/RAF LAKENHEATH
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:48 MDG/RAF LAKENHEATH
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09461
Practice Address - Country:US
Practice Address - Phone:314-226-8317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062855-011223G0001X
NJ22DI029007001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice