Provider Demographics
NPI:1053540526
Name:KIM, ALISA (DMD)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1118
Mailing Address - Country:US
Mailing Address - Phone:585-637-3905
Mailing Address - Fax:585-637-4990
Practice Address - Street 1:300 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1118
Practice Address - Country:US
Practice Address - Phone:585-637-3905
Practice Address - Fax:585-637-4990
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP71309122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist