Provider Demographics
NPI:1134105430
Name:KIM, JONGSUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONGSUNG
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 1:51DS
Mailing Address - Street 2:PSC3, BOX 1622
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96266
Mailing Address - Country:KP
Mailing Address - Phone:01182103-888-9453
Mailing Address - Fax:0118231-661-6674
Practice Address - Street 1:51MDG/51DS
Practice Address - Street 2:UNIT 2060
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:KP
Practice Address - Phone:0118231-661-2108
Practice Address - Fax:0118231-661-6674
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice