Provider Demographics
NPI:1730416900
Name:KIM, KEN KWANGDEOK (DMD)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:KWANGDEOK
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 1:1163 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5029
Mailing Address - Country:US
Mailing Address - Phone:516-932-7171
Mailing Address - Fax:516-932-7707
Practice Address - Street 1:1163 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-5029
Practice Address - Country:US
Practice Address - Phone:516-932-7171
Practice Address - Fax:516-932-7707
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024244001223G0001X
NY0552441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice