Provider Demographics
NPI:1174818496
Name:KIM, JUNG H (DDS)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:H
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 1:2175 HUDSON TER APT 7I
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7715
Mailing Address - Country:US
Mailing Address - Phone:201-676-0029
Mailing Address - Fax:
Practice Address - Street 1:309A BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1620
Practice Address - Country:US
Practice Address - Phone:201-242-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0560541223X0400X
NJ22DI025045001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP77908OtherNY STATE TEACHING PERMIT NO
NY034481918Medicaid