1356406458 NPI number — DR. BENEDICT HEEKYU KIM D.D.S.

Table of content: (NPI 1104164862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356406458 NPI number — DR. BENEDICT HEEKYU KIM D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
BENEDICT
Provider Middle Name:
HEEKYU
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356406458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36309 MONTROSE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44011-3495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-934-0715
Provider Business Mailing Address Fax Number:
440-934-0716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3865 ROCKY RIVER DR
Provider Second Line Business Practice Location Address:
SUITE #6
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44111-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-251-8826
Provider Business Practice Location Address Fax Number:
216-251-8464
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  19888 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0003072 . This is a "ASSURANT" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: J671066 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 213158 . This is a "CIGNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 994487 . This is a "COMPNET PPO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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