Healthcare Provider Details

I. General information

NPI: 1649332891
Provider Name (Legal Business Name): GREG YOOKYONG KIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9690 W TROPICANA AVE #100
LAS VEGAS NV
89147-2601
US

IV. Provider business mailing address

9690 W TROPICANA AVE #100
LAS VEGAS NV
89147-2601
US

V. Phone/Fax

Practice location:
  • Phone: 702-876-0000
  • Fax:
Mailing address:
  • Phone: 702-876-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberS7-80C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: