=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295473015
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIN-YOUNG KIM CASE DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2022
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3590 BRASELTON HWY STE 100
-----------------------------------------------------
City | DACULA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30019-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-448-8882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 RALPH MCGILL BLVD NE APT 2607
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30312-1156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-389-8514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN123619
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN123619
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | RES.004524
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------