Active NPI
Dong Won Kim, D.M.D.
- Dentist
- Lowell, MA
National Provider Identifier
1679694293
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 21536
- Practice address
- 133 Market St
Lowell, MA 01852-1808 - Phone
- (978) 458-1179
- Fax
- (978) 805-1415
- NPI assigned
- Apr 2, 2007
- Reactivated
- Nov 19, 2019
- Last updated
- Jan 26, 2023
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 21536 | MA | Primary |
Addresses
Primary practice location
133 Market St
Lowell, MA 01852-1808
Mailing address
3600 Mystic Valley Pkwy
Apt # 709
Medford, MA 02155-5733
Phone (781) 393-4830
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0207110 | Medicaid | MA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160413001506 | MA | Order and Referring Only - Dentist | 3971801671 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 21536 | MA | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1175472000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1674691200000",
"number": "1679694293",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3600 MYSTIC VALLEY PKWY",
"address_2": "APT # 709",
"city": "MEDFORD",
"state": "MA",
"postal_code": "021555733",
"telephone_number": "781-393-4830"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "133 MARKET ST",
"city": "LOWELL",
"state": "MA",
"postal_code": "018521808",
"telephone_number": "978-458-1179",
"fax_number": "978-805-1415"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KIM",
"first_name": "DONG",
"middle_name": "WON",
"name_prefix": "Dr.",
"credential": "D.M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-04-02",
"last_updated": "2023-01-26",
"certification_date": "2023-01-26",
"deactivation_date": "2019-11-07",
"reactivation_date": "2019-11-19",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MA",
"license": "21536",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0207110",
"state": "MA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Lowell, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2023; 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.