MEDICARE: DAE YOUNG KIM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401417975	VA

General Provider Information

NPI Number	:	1427775766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAE YOUNG KIM

Provider Business Mailing Address
First Line	:	3851 ARISTOTLE CT APT 309
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-7491
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 CEDAR CREEK GRADE STE 211
Second Line	:
City	:	WINCHESTER
State	:	VA
Zip	:	22601-6454
Country	:	US
Telephone Number	:	540-486-5111
Fax Number	:	888-699-6657

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2022
Last Update Date	:	10/27/2022

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