Provider Demographics
NPI:1093207235
Name:KIM, GRACE JIAE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:JIAE
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1769
Mailing Address - Country:US
Mailing Address - Phone:201-886-8400
Mailing Address - Fax:
Practice Address - Street 1:1315 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-1769
Practice Address - Country:US
Practice Address - Phone:201-886-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323611223X0400X
NY0596901223X0400X
NJ22DI027195001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics