Healthcare Provider Details

I. General information

NPI: 1801571021
Provider Name (Legal Business Name): THOMAS KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 LAFAYETTE RD
SEABROOK NH
03874-4345
US

IV. Provider business mailing address

20722 JORDAN DR
BAYSIDE NY
11360-1183
US

V. Phone/Fax

Practice location:
  • Phone: 603-760-7119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number04878
License Number StateNH
# 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: