Healthcare Provider Details

I. General information

NPI: 1346458965
Provider Name (Legal Business Name): KIM LYVAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 CANAL STREET #201
NEW YORK NY
10013
US

IV. Provider business mailing address

199 CANAL STREET #201
NEW YORK NY
10013
US

V. Phone/Fax

Practice location:
  • Phone: 212-274-9022
  • Fax:
Mailing address:
  • Phone: 212-274-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number042981
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI01882200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: