Provider Demographics
NPI:1548529928
Name:KIM, STEWART Y (DDS)
Entity type:Individual
Prefix:
First Name:STEWART
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARIEL CT
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4373
Mailing Address - Country:US
Mailing Address - Phone:917-645-2555
Mailing Address - Fax:
Practice Address - Street 1:10 MARIEL CT
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-4373
Practice Address - Country:US
Practice Address - Phone:917-645-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT110521223G0001X
NY0569411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice