Provider Demographics
NPI:1164677746
Name:KIM, JI IN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JI
Middle Name:IN
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 1:150 E CENTENNIAL PKWY STE 113
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-1338
Mailing Address - Country:US
Mailing Address - Phone:702-642-1386
Mailing Address - Fax:702-642-6321
Practice Address - Street 1:150 E CENTENNIAL PKWY STE 113
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084
Practice Address - Country:US
Practice Address - Phone:702-642-1386
Practice Address - Fax:702-642-6321
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57816122300000X
NV6120122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist