Basic Information
| Provider Information | |||||||||
| NPI: | 1912100157 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAEWONKIM DDS, PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 455 REVOLUTION ST | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210783330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109393890 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 455 REVOLUTION ST | ||||||||
| Address2: | |||||||||
| City: | HAVRE DE GRACE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210783330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109393890 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4109393890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 10839 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.