Provider Demographics
NPI:1598287484
Name:KIM, ALEXANDER Y (DDS)
Entity type:Individual
Prefix:
First Name:ALEXANDER
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 1:1212 LEANING OAK LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2544
Mailing Address - Country:US
Mailing Address - Phone:847-636-7612
Mailing Address - Fax:
Practice Address - Street 1:36000 SHOEMAKER LANE
Practice Address - Street 2:SUITE 1051
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10680122300000X
TX366161223G0001X
UT14181273-99261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist