Provider Demographics
NPI:1649636473
Name:KIM, YOUNG JOO (DMD)
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:JOO
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 1:3300 SHIPLEY ST
Mailing Address - Street 2:APT 1126
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4144
Mailing Address - Country:US
Mailing Address - Phone:843-900-4584
Mailing Address - Fax:
Practice Address - Street 1:320 MIDLAND PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-7197
Practice Address - Country:US
Practice Address - Phone:843-900-4584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice