=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922140425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYUNG IL KIM DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 20 45 ROAD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-229-6202
-----------------------------------------------------
Fax | 718-229-1655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 20 45 ROAD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-229-6202
-----------------------------------------------------
Fax | 718-229-1655
-----------------------------------------------------
=====================================================
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 | 042495
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------