=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417768227
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YOOME KIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2025
-----------------------------------------------------
Last Update Date | 01/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 ORANGE ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07107-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-481-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 GREENWAY DR
-----------------------------------------------------
City | LEONIA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07605-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-658-6233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI03075100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------