1386165736 NPI number — DR. SUSUN THERESA KIM DMD

Table of content: DR. SUSUN THERESA KIM DMD (NPI 1386165736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386165736 NPI number — DR. SUSUN THERESA KIM DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
SUSUN
Provider Middle Name:
THERESA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

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:
1386165736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
59 DG AF POSTGRADUATE DENTAL SCHOOL
Provider Second Line Business Mailing Address:
2133 KLINKER STREET, BUILDING 3352
Provider Business Mailing Address City Name:
JBSA-LACKLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78236-5313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-228-3838
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4175 SOUTH ALAMO AVENUE
Provider Second Line Business Practice Location Address:
355 MDG
Provider Business Practice Location Address City Name:
DAVIS-MONTHAN AFB
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85707-4406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-228-2650
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2017

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: 1223P0700X , with the licence number:  22DI02757700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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