Provider Demographics
NPI:1962997130
Name:KIM, BOMI (DDS)
Entity type:Individual
Prefix:
First Name:BOMI
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 1:4807 TWINBROOK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2047
Mailing Address - Country:US
Mailing Address - Phone:703-967-0036
Mailing Address - Fax:
Practice Address - Street 1:563 JAMES MADISON HWY
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-2365
Practice Address - Country:US
Practice Address - Phone:540-827-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014161171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice