Provider Demographics
NPI:1144439720
Name:KIM, JEONG E (DDS)
Entity type:Individual
Prefix:
First Name:JEONG
Middle Name:E
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 S LA FAYETTE PARK PL APT 207
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1385
Mailing Address - Country:US
Mailing Address - Phone:213-820-3398
Mailing Address - Fax:
Practice Address - Street 1:450 S GLENDORA AVE
Practice Address - Street 2:STE. 106
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3066
Practice Address - Country:US
Practice Address - Phone:626-856-3317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD54452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD54452OtherSTATE LICENSE