MEDICARE: SEONJEONG 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	7074	AZ

General Provider Information

NPI Number	:	1528246162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEONJEONG KIM

Provider Business Mailing Address
First Line	:	3212 N WINDSONG DR STE 200
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-2255
Country	:	US
Telephone Number	:	928-583-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3212 N WINDSONG DR STE 200
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-2255
Country	:	US
Telephone Number	:	928-583-1000
Fax Number	:

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

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	06/02/2026

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Directions to “ SEONJEONG KIM ” Practice Location

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