Provider Demographics
NPI:1245996784
Name:KIM, NATHAN DAEBHUM (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:DAEBHUM
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5603 OROUKE RD
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2153
Mailing Address - Country:US
Mailing Address - Phone:678-702-3050
Mailing Address - Fax:
Practice Address - Street 1:179 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7716
Practice Address - Country:US
Practice Address - Phone:714-288-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL269561223G0001X
390200000X
CADDS109885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program