=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609436989
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANWOOL KIM DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2019
-----------------------------------------------------
Last Update Date | 06/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8303 ARLINGTON BLVD STE 104
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-207-0700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8059 ASHLAND AVE APT 11
-----------------------------------------------------
City | MANASSAS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20109-8059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-717-8408
-----------------------------------------------------
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 | 0401416449
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------