MEDICARE: DR. MINNA 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	21223	MA
2	122300000X	Dentist	DEN.00205298	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	X10267	OTHER	MA	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1437249497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MINNA KIM DMD

Provider Business Mailing Address
First Line	:	6442 FALCON RIDGE CT
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-9162
Country	:	US
Telephone Number	:	781-799-1357
Fax Number	:

Provider Business Practice Location Address
First Line	:	2117 CUSTER DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3684
Country	:	US
Telephone Number	:	970-221-3700
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	04/29/2024

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