Provider Demographics
NPI:1679319313
Name:KIM, ROLA (DMD)
Entity type:Individual
Prefix:DR
First Name:ROLA
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 1:10419 DEARLOVE RD APT A1
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3527
Mailing Address - Country:US
Mailing Address - Phone:224-361-6908
Mailing Address - Fax:
Practice Address - Street 1:1204 HIGHWAY 164 E
Practice Address - Street 2:
Practice Address - City:OQUAWKA
Practice Address - State:IL
Practice Address - Zip Code:61469-3204
Practice Address - Country:US
Practice Address - Phone:309-867-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190352741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice