Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 16647 | MD |
NPI | 1093169344 |
---|---|
Provider Name | Dr. Su Jin Kim |
First Address | Baltimore, MD 21201-1510 |
Second Address | Finksburg, MD 21048-1630 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2016 |
Last Update Date | 26/02/2020 |