Healthcare Provider Details

I. General information

NPI: 1386320232
Provider Name (Legal Business Name): TAE KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E. 24TH STREET NEW YORK, NY 10010
NEW YORK NY
10010
US

IV. Provider business mailing address

345 E. 24TH STREET NEW YORK, NY 10010
NEW YORK NY
10010
US

V. Phone/Fax

Practice location:
  • Phone: 212-998-9800
  • Fax:
Mailing address:
  • Phone: 212-998-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00206711
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: