Provider Demographics
NPI:1083084404
Name:KIM, JONATHAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
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 1:4323 TACOMA TRCE
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-8731
Mailing Address - Country:US
Mailing Address - Phone:678-361-6213
Mailing Address - Fax:
Practice Address - Street 1:1830 SCENIC HWY N STE 220
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2100
Practice Address - Country:US
Practice Address - Phone:770-844-9454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2022-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65136122300000X
WA60793892122300000X
GADN122806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist