Provider Demographics
NPI:1447349733
Name:KIM, SUSAN J (DDS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 W MCDERMOTT DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6387
Mailing Address - Country:US
Mailing Address - Phone:972-359-1300
Mailing Address - Fax:972-359-1480
Practice Address - Street 1:1212 W MCDERMOTT DR
Practice Address - Street 2:SUITE 300
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6387
Practice Address - Country:US
Practice Address - Phone:972-359-1300
Practice Address - Fax:972-359-1480
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20132OtherTX STATE DENTAL LICENSE
7706223384OtherFEDERAL TAX ID NUMBER