Healthcare Provider Details

I. General information

NPI: 1134343924
Provider Name (Legal Business Name): JAMES S KIM DDS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S 24TH AVE STE 200
WAUSAU WI
54401-5225
US

IV. Provider business mailing address

501 S 24TH AVE STE 200
WAUSAU WI
54401-5225
US

V. Phone/Fax

Practice location:
  • Phone: 715-849-5667
  • Fax: 715-849-5667
Mailing address:
  • Phone: 715-849-5667
  • Fax: 715-849-5667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number4878
License Number StateWI

VIII. Authorized Official

Name: DR. JAMES S KIM
Title or Position: PRESIDENT
Credential: DDS
Phone: 715-849-5667