MEDICARE: SAMUEL EUNGOOK 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	14093	CT
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	22DI03027100	NJ

General Provider Information

NPI Number	:	1437783107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL EUNGOOK KIM

Provider Business Mailing Address
First Line	:	7 LINWOOD RD N
Second Line	:
City	:	PORT WASHINGTON
State	:	NY
Zip	:	11050-1411
Country	:	US
Telephone Number	:	516-497-8068
Fax Number	:

Provider Business Practice Location Address
First Line	:	385 S MAPLE AVE STE 207
Second Line	:
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1545
Country	:	US
Telephone Number	:	201-380-2236
Fax Number	:

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

Provider Enumeration Date	:	03/02/2020
Last Update Date	:	08/08/2024

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