Provider Demographics
NPI:1053350116
Name:KIM, WILSON (DDS)
Entity type:Individual
Prefix:DR
First Name:WILSON
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 1:1316 COLVIN FOREST DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-1318
Mailing Address - Country:US
Mailing Address - Phone:917-449-2776
Mailing Address - Fax:703-992-7284
Practice Address - Street 1:8251 GREENSBORO DR
Practice Address - Street 2:SUITE #102
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4900
Practice Address - Country:US
Practice Address - Phone:702-992-7272
Practice Address - Fax:703-992-7284
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014110021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice