Provider Demographics
NPI:1083832273
Name:KIM, JAE GWON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:GWON
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 1:777 N. RAINBOW BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107
Mailing Address - Country:US
Mailing Address - Phone:702-326-7746
Mailing Address - Fax:
Practice Address - Street 1:777 N. RAINBOW BLVD.
Practice Address - Street 2:STE. 395
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107
Practice Address - Country:US
Practice Address - Phone:702-939-2875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3356122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist