MEDICARE: GINA KIM DDS PC

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	122300000X	Dentist	019026234	IL

General Provider Information

NPI Number	:	1851796486
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GINA KIM DDS PC

Provider Business Mailing Address
First Line	:	3748 N ASHLAND AVE
Second Line	:	2N
City	:	CHICAGO
State	:	IL
Zip	:	60613
Country	:	US
Telephone Number	:	773-592-5562
Fax Number	:

Provider Business Practice Location Address
First Line	:	2833 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-7403
Country	:	US
Telephone Number	:	773-772-8400
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. GINA KIM
Credential	:	DDS
Telephone Number	:	773-592-5562

Provider Enumeration Date	:	10/24/2014
Last Update Date	:	10/24/2014

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