Provider Demographics
NPI:1053729467
Name:KIM, MARY GRACE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:GRACE
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 W. PETERSON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-761-0300
Mailing Address - Fax:773-761-0009
Practice Address - Street 1:8321 W GOLF RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1113
Practice Address - Country:US
Practice Address - Phone:847-720-3504
Practice Address - Fax:847-692-5271
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190299221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019029922Medicaid