Healthcare Provider Details

I. General information

NPI: 1851023626
Provider Name (Legal Business Name): DAEJIN MICHAEL KIM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST
NEWARK NJ
07103-2495
US

IV. Provider business mailing address

101 LAFAYETTE ST FL 9
NEW YORK NY
10013-4153
US

V. Phone/Fax

Practice location:
  • Phone: 888-217-2470
  • Fax:
Mailing address:
  • Phone: 212-842-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number064748
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI03138600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: