=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255872016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SUN HYUN KIM DMD P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2017
-----------------------------------------------------
Last Update Date | 03/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 556 GARRISONVILLE RD STE 208
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-7826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-699-2414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 556 GARRISONVILLE RD STE 208
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-7826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SUN H KIM
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 540-699-2414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0141412496
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------