Healthcare Provider Details

I. General information

NPI: 1235813841
Provider Name (Legal Business Name): MICHELLE KIM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA KIM DMD

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHLAND AVE STE 201
SALEM MA
01970-2702
US

IV. Provider business mailing address

30 REVERE BEACH PKWY APT 313
MEDFORD MA
02155-5162
US

V. Phone/Fax

Practice location:
  • Phone: 617-475-0190
  • Fax:
Mailing address:
  • Phone: 617-631-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1859882
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: