Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 0401006468 | VA |
NPI | 1336207554 |
---|---|
Provider Name | Dr. Dongsup Kim |
First Address | Fairfax, VA 22032-1904 |
Second Address | Fairfax, VA 22032-1904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |