Healthcare Provider Details

I. General information

NPI: 1427775766
Provider Name (Legal Business Name): DAE YOUNG KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 HERITAGE VILLAGE PLZ STE 102
GAINESVILLE VA
20155-3070
US

IV. Provider business mailing address

3851 ARISTOTLE CT APT 309
FAIRFAX VA
22030-7491
US

V. Phone/Fax

Practice location:
  • Phone: 703-348-4299
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401417975
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: