Provider Demographics
NPI:1700486438
Name:KIM, JANE JEEYOON (DMD)
Entity type:Individual
Prefix:DR
First Name:JANE
Middle Name:JEEYOON
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4568 SW 160TH AVE APT F
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97078-8804
Mailing Address - Country:US
Mailing Address - Phone:503-332-7791
Mailing Address - Fax:
Practice Address - Street 1:14425 SW ALLEN BLVD # 1
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4402
Practice Address - Country:US
Practice Address - Phone:503-644-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD113601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice