Provider Demographics
NPI:1871727933
Name:KIM, RANDOLPH (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 CONNECTICUT AVE NW
Mailing Address - Street 2:SUITE L 08
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-2406
Mailing Address - Country:US
Mailing Address - Phone:202-362-5596
Mailing Address - Fax:
Practice Address - Street 1:3601 CONNECTICUT AVE NW
Practice Address - Street 2:SUITE L 08
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-2406
Practice Address - Country:US
Practice Address - Phone:202-362-5596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10010621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice