Provider Demographics
NPI:1679995955
Name:KIM, SUNG RAE
Entity type:Individual
Prefix:
First Name:SUNG RAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 PIERMONT ROAD
Mailing Address - Street 2:SUITE C1
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:570 PIERMONT RD
Practice Address - Street 2:SUITE C1
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-3100
Practice Address - Country:US
Practice Address - Phone:201-666-2828
Practice Address - Fax:201-750-2314
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI197511223P0700X
NJ22DI01975100122300000X
NY047461-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist