MEDICARE: DR. DONGSU KIM DDS

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	DN28875	FL

General Provider Information

NPI Number	:	1730884560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONGSU KIM DDS

Provider Business Mailing Address
First Line	:	311 E 25TH ST APT 5F
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10010-2501
Country	:	US
Telephone Number	:	804-937-9680
Fax Number	:

Provider Business Practice Location Address
First Line	:	1799 N WILLIAMSON BLVD APT 7210
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-5309
Country	:	US
Telephone Number	:	804-937-9680
Fax Number	:

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

Provider Enumeration Date	:	04/03/2023
Last Update Date	:	01/08/2025

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