=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649813163
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KI YOUN KIL DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2019
-----------------------------------------------------
Last Update Date | 12/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1379 MORRIS AVE STE 1
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-3340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-882-0196
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 E 119TH ST APT 3B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10035-4287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-460-6661
-----------------------------------------------------
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 | 065048
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 22DI03119900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------