Provider Demographics
NPI:1942044946
Name:KIM, MIN (DMD)
Entity type:Individual
Prefix:MS
First Name:MIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
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:SCS SHAWANO 1200 ENGEL DRIVE
Mailing Address - Street 2:APT 106
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166
Mailing Address - Country:US
Mailing Address - Phone:479-871-9656
Mailing Address - Fax:
Practice Address - Street 1:15397 WI-32
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138
Practice Address - Country:US
Practice Address - Phone:715-276-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001567-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice