Provider Demographics
NPI:1033365689
Name:KIM, JESSICA JUNGHWA (DDS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JUNGHWA
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JUNGHWA
Other - Middle Name:
Other - Last Name:SUH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:11092 ANDERSON STREET
Mailing Address - Street 2:LLU SCHOOL OF DENTISTRY
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-4613
Mailing Address - Fax:909-558-4192
Practice Address - Street 1:11092 ANDERSON STREET
Practice Address - Street 2:LLU SCHOOL OF DENTISTRY
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:95350-0001
Practice Address - Country:US
Practice Address - Phone:909-558-4613
Practice Address - Fax:909-558-4192
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55009OtherSTATE LICENSES