Provider Demographics
NPI:1992886592
Name:KIM, MARIA WONG (DMD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:WONG
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:6309 HAZELWEST CT
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1739
Mailing Address - Country:US
Mailing Address - Phone:314-731-1688
Mailing Address - Fax:314-731-7938
Practice Address - Street 1:6309 HAZELWEST CT
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1739
Practice Address - Country:US
Practice Address - Phone:314-731-1688
Practice Address - Fax:314-731-7938
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist