1609988153 NPI number — JOHN G CLINTHORNE DDS MS & HEAWON LUDIA KIM DMD MS PC

Table of content: (NPI 1609988153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609988153 NPI number — JOHN G CLINTHORNE DDS MS & HEAWON LUDIA KIM DMD MS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN G CLINTHORNE DDS MS & HEAWON LUDIA KIM DMD MS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1609988153
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1303 PACKARD ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48104-3814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-761-3116
Provider Business Mailing Address Fax Number:
734-761-5263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 PACKARD ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48104-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-761-3116
Provider Business Practice Location Address Fax Number:
734-761-5263
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
HEAWON
Authorized Official Middle Name:
LUDIA
Authorized Official Title or Position:
SECRETARY TREASURER OF PC
Authorized Official Telephone Number:
734-761-3116

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  2901016885 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 2901012468 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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