MEDICARE: KEN KIM

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	12964	MD

General Provider Information

NPI Number	:	1477606341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEN KIM

Provider Business Mailing Address
First Line	:	8801 BALTIMORE NATIONAL PIKE STE 17
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-4160
Country	:	US
Telephone Number	:	410-461-2424
Fax Number	:

Provider Business Practice Location Address
First Line	:	8801 BALTIMORE NATIONAL PIKE #17
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043
Country	:	US
Telephone Number	:	410-461-2424
Fax Number	:

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	03/09/2010

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Directions to “ KEN KIM ” Practice Location

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