Provider Demographics
NPI:1447372420
Name:GAN, KIM S (DDS, PT, PC)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:S
Last Name:GAN
Suffix:
Gender:M
Credentials:DDS, PT, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 W COLFAX AVE STE B160
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-3754
Mailing Address - Country:US
Mailing Address - Phone:303-238-6880
Mailing Address - Fax:303-202-9412
Practice Address - Street 1:12600 W COLFAX AVE STE B160
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-3754
Practice Address - Country:US
Practice Address - Phone:303-238-6880
Practice Address - Fax:303-202-9412
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD9681041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice