Provider Demographics
NPI:1548080062
Name:KIM, JINSEONG
Entity type:Individual
Prefix:
First Name:JINSEONG
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 1:26149 PARK AVE UNIT 18
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6128
Mailing Address - Country:US
Mailing Address - Phone:951-776-6038
Mailing Address - Fax:
Practice Address - Street 1:26149 PARK AVE UNIT 18
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-6128
Practice Address - Country:US
Practice Address - Phone:951-776-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110848122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist