MEDICARE: DR. RICHARD JAY KIM DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401412329	VA

General Provider Information

NPI Number	:	1104062009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD JAY KIM DMD

Provider Business Mailing Address
First Line	:	858 CLUB RIDGE TER
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23836-2746
Country	:	US
Telephone Number	:	804-530-0245
Fax Number	:	804-530-0245

Provider Business Practice Location Address
First Line	:	400 GALLERIA PKWY SE
Second Line	:	SUITE 800
City	:	ATLANTA
State	:	GA
Zip	:	30339-5980
Country	:	US
Telephone Number	:	678-904-5665
Fax Number	:	678-904-5665

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2008
Last Update Date	:	12/23/2008

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