Healthcare Provider Details

I. General information

NPI: 1962199364
Provider Name (Legal Business Name): CASEY SEOL KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 06/11/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-688-3763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.027812
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES.004612
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: