Provider Demographics
NPI:1104036797
Name:KIM, JONATHAN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:J
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 1:23 GREENWICH AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10917-3717
Mailing Address - Country:US
Mailing Address - Phone:845-827-6470
Mailing Address - Fax:
Practice Address - Street 1:2 SUMMIT CT
Practice Address - Street 2:SUITE 206
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-1348
Practice Address - Country:US
Practice Address - Phone:845-896-9192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY48088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist