Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1285925669 |
---|---|
Provider Name | Wan Kim |
First Address | Suwanee, GA 30024-2013 |
Second Address | Suwanee, GA 30024-2013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2011 |
Last Update Date | 20/04/2011 |