Healthcare Provider Details

I. General information

NPI: 1609983535
Provider Name (Legal Business Name): HEE SOO KIM D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MAIN ST
GREEN BAY WI
54301-5115
US

IV. Provider business mailing address

400 E WAYFARER LN
APPLETON WI
54913-6358
US

V. Phone/Fax

Practice location:
  • Phone: 920-431-0345
  • Fax:
Mailing address:
  • Phone: 920-954-8633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5052-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: