Provider Demographics
NPI:1144003104
Name:KIM, JENNIE (DMD)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JI HYUN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2624 SWEETBROOM RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-4325
Mailing Address - Country:US
Mailing Address - Phone:715-491-5118
Mailing Address - Fax:
Practice Address - Street 1:55 S MAIN ST STE 241
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5377
Practice Address - Country:US
Practice Address - Phone:630-848-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034508122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist