Basic Information
| Provider Information | |||||||||
| NPI: | 1104062009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 858 CLUB RIDGE TER | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238362746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045300245 | ||||||||
| FaxNumber: | 8045300245 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 GALLERIA PKWY SE | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789045665 | ||||||||
| FaxNumber: | 6789045665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2008 | ||||||||
| LastUpdateDate: | 12/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0401412329 | VA | Y | Dental Providers | Dentist | General Practice |
No ID Information.