Healthcare Provider Details

I. General information

NPI: 1760372320
Provider Name (Legal Business Name): HYEONGU KIM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 STONY HILL RD STE 101
BETHEL CT
06801-1045
US

IV. Provider business mailing address

15 FARM SPRINGS RD APT 134
FARMINGTON CT
06032-2588
US

V. Phone/Fax

Practice location:
  • Phone: 203-850-7990
  • Fax:
Mailing address:
  • Phone: 204-891-0169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14885
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: