Basic Information
| Provider Information | |||||||||
| NPI: | 1588870117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | NIGEL | ||||||||
| MiddleName: | JASON | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 W BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184831217 | ||||||||
| FaxNumber: | 7182287471 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 W BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184831270 | ||||||||
| FaxNumber: | 7182287471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 09/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 052373-1 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 052373 | 01 | NY | LICENSE# | OTHER | 02693378-003 | 05 | NY | MEDICAID |