Healthcare Provider Details

I. General information

NPI: 1770041683
Provider Name (Legal Business Name): MINSUNG BRADLEY KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MINSUNG KIM

II. Dates (important events)

Enumeration Date: 03/10/2019
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 MILLTOWN RD STE 17
WILMINGTON DE
19808-4084
US

IV. Provider business mailing address

1601 MILLTOWN RD STE 17
WILMINGTON DE
19808-4084
US

V. Phone/Fax

Practice location:
  • Phone: 302-995-1870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberG1-0011631
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: