Provider Demographics
NPI:1053661207
Name:KIM, JIYOON (DMD)
Entity Type:Individual
Prefix:
First Name:JIYOON
Middle Name:
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 1:450 N END AVE APT 20D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10282-1111
Mailing Address - Country:US
Mailing Address - Phone:352-222-3267
Mailing Address - Fax:
Practice Address - Street 1:230 W 41ST ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7207
Practice Address - Country:US
Practice Address - Phone:516-407-9561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28381122300000X
NY057710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty