Provider Demographics
NPI:1174939607
Name:KIM, MINJI
Entity type:Individual
Prefix:DR
First Name:MINJI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-2643
Mailing Address - Country:US
Mailing Address - Phone:845-358-5110
Mailing Address - Fax:
Practice Address - Street 1:505 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5834
Practice Address - Country:US
Practice Address - Phone:617-639-5942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-04
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN 1856604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist