Provider Demographics
NPI:1144537333
Name:JOHN M KIM DMD PC
Entity type:Organization
Organization Name:JOHN M KIM DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MITOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-429-7122
Mailing Address - Street 1:3102 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8609
Mailing Address - Country:US
Mailing Address - Phone:269-429-7122
Mailing Address - Fax:269-429-6410
Practice Address - Street 1:3102 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8609
Practice Address - Country:US
Practice Address - Phone:269-429-7122
Practice Address - Fax:269-429-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0143471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2983370Medicaid
MIU05429Medicare UPIN
MI5116012Medicare PIN