=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588143754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHY CHONG EUN KIM DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2018
-----------------------------------------------------
Last Update Date | 05/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4760 W MINERAL AVE STE 60
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80128-2540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-327-9553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 S MONROE ST APT 523
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80209-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-236-4520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DEN.00203655
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------