Mary Kim, D.M.D.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DN122544 Issued in GA

Practice address

2424 W Peterson Ave
Chicago, IL 60659-4100

Phone

(773) 761-0300

Fax

(773) 761-0300

NPI assigned

Mar 18, 2017

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Southside Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Atlanta, GA
  • NPI 1235123993
  Medicare reassignment NPD
• Southside Medical Center, Inc

  dba Southside Medical Center School Based Health Center at Lee Elementary School

  • Federally Qualified Health Center (FQHC)
  • Jonesboro, GA
  • NPI 1821981234
  NPD
• Summit Medical Group, Inc

  dba St. Elizabeth Physicians

  • Family Medicine Physician
  • Erlanger, KY
  • NPI 1750343216
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1489795200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1646092800000",
    "number": "1184165516",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "500 PRESTWICK LN",
            "city": "WHEELING",
            "state": "IL",
            "postal_code": "600906231",
            "telephone_number": "847-668-0125"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2424 W PETERSON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606594100",
            "telephone_number": "773-761-0300",
            "fax_number": "773-761-0300"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "8321 W Golf Rd",
            "address_purpose": "LOCATION",
            "city": "Niles",
            "state": "IL",
            "postal_code": "607141113",
            "country_code": "US",
            "telephone_number": "773-761-0300",
            "fax_number": "773-761-0009",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "8800 Lockwood Ave",
            "address_purpose": "LOCATION",
            "city": "Skokie",
            "state": "IL",
            "postal_code": "600771500",
            "country_code": "US",
            "telephone_number": "773-761-0300",
            "fax_number": "773-761-0009",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "251 E Huron St",
            "address_purpose": "LOCATION",
            "city": "Chicago",
            "state": "IL",
            "postal_code": "606112908",
            "country_code": "US",
            "telephone_number": "312-926-2000",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2501 W Peterson Ave",
            "address_purpose": "LOCATION",
            "city": "Chicago",
            "state": "IL",
            "postal_code": "60659",
            "country_code": "US",
            "telephone_number": "773-761-0300",
            "fax_number": "773-761-0009",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KIM",
        "first_name": "MARY",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-03-18",
        "last_updated": "2022-03-01",
        "certification_date": "2022-03-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019031189",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "TX",
            "license": "34965",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "GA",
            "license": "DN122544",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Leeseul Kim, MD
• Lily Kim, RDN, LDN
• Lisa Jisun Kim, MD
• Lotus Kim, NP
• Marcus Kim, PHARMD
• Mary Ann Kim, DDS
• Max H Kim, D.D.S.
• Mi Kyung Kim, M.D.
• Michael Kim
• Michelle Julie Kim, MD

• General Practice Dentistry in Chicago, IL
• Providers in Chicago, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.