Healthcare Provider Details

I. General information

NPI: 1215787239
Provider Name (Legal Business Name): JUNYOUNG KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 10TH AVE SW
WAVERLY IA
50677-3752
US

IV. Provider business mailing address

1232 LOIS LN
WATERLOO IA
50702-4243
US

V. Phone/Fax

Practice location:
  • Phone: 319-352-5222
  • Fax:
Mailing address:
  • Phone: 469-426-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS-10226
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: