Provider Demographics
NPI:1023398344
Name:KIM, JESSE GAWSUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:GAWSUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7190 DAVENPORT RD APT 110
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2932
Mailing Address - Country:US
Mailing Address - Phone:408-497-0161
Mailing Address - Fax:
Practice Address - Street 1:7190 DAVENPORT RD APT 110
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2932
Practice Address - Country:US
Practice Address - Phone:408-497-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60554122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice