=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679995955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUNG RAE KIM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2014
-----------------------------------------------------
Last Update Date | 01/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 570 PIERMONT RD SUITE C1
-----------------------------------------------------
City | CLOSTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07624-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-666-2828
-----------------------------------------------------
Fax | 201-750-2314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 570 PIERMONT ROAD SUITE C1
-----------------------------------------------------
City | CLOSTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DI19751
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI01975100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 047461-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------