Provider Demographics
NPI:1033543525
Name:KIM, JAE YOUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAE YOUNG
Middle Name:
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 1:1942 WASHINGTON ST
Mailing Address - Street 2:#219
Mailing Address - City:AUBURNDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02466-3042
Mailing Address - Country:US
Mailing Address - Phone:718-366-4192
Mailing Address - Fax:
Practice Address - Street 1:1942 WASHINGTON ST
Practice Address - Street 2:#219
Practice Address - City:AUBURNDALE
Practice Address - State:MA
Practice Address - Zip Code:02466-3042
Practice Address - Country:US
Practice Address - Phone:781-366-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL12040122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist