Provider Demographics
NPI:1174679740
Name:KIM, JUNG-MIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUNG-MIN
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 1:100 OLD PALISADE RD APT 2705
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7022
Mailing Address - Country:US
Mailing Address - Phone:646-436-4709
Mailing Address - Fax:212-564-1161
Practice Address - Street 1:57 W 57TH ST STE 710
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019
Practice Address - Country:US
Practice Address - Phone:212-564-1888
Practice Address - Fax:212-564-1161
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02280100122300000X
NY051532122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02594154Medicaid
NY02594154Medicaid