MEDICARE: KI YOUN KIL 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	065048	NY
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	22DI03119900	NJ

General Provider Information

NPI Number	:	1649813163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KI YOUN KIL DMD

Provider Business Mailing Address
First Line	:	330 E 119TH ST APT 3B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-4287
Country	:	US
Telephone Number	:	917-460-6661
Fax Number	:

Provider Business Practice Location Address
First Line	:	1379 MORRIS AVE STE 1
Second Line	:
City	:	UNION
State	:	NJ
Zip	:	07083-3340
Country	:	US
Telephone Number	:	908-882-0196
Fax Number	:

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

Provider Enumeration Date	:	10/28/2019
Last Update Date	:	12/31/2025

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