Healthcare Provider Details

I. General information

NPI: 1174958516
Provider Name (Legal Business Name): HYEONG C. KIM, DDS, PHD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 63RD DR
REGO PARK NY
11374-3849
US

IV. Provider business mailing address

9101 63RD DR
REGO PARK NY
11374-3849
US

V. Phone/Fax

Practice location:
  • Phone: 718-565-5445
  • Fax: 718-565-0952
Mailing address:
  • Phone: 718-565-5445
  • Fax: 718-565-0952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number055881-1
License Number StateNY

VIII. Authorized Official

Name: DR. HYEONG CHAN KIM
Title or Position: DENTIST
Credential: D.D.S., PH.D.
Phone: 718-565-5445