Basic Information
| Provider Information | |||||||||
| NPI: | 1154487445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SEONGRYEOL | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11825 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | DUNLAP | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092431541 | ||||||||
| FaxNumber: | 3092438188 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 NW ANDERSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983839161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603371780 | ||||||||
| FaxNumber: | 3092438188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
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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 | 122300000X | DE00010423 | WA | N | Dental Providers | Dentist | 122300000X | 019028319 | IL | Y | Dental Providers | Dentist |
No ID Information.