Provider Demographics
NPI:1235534157
Name:KIM, JANICE S (DMD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:S
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 GRAND AVENUE PARKWAY
Mailing Address - Street 2:SUITE150
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660
Mailing Address - Country:US
Mailing Address - Phone:512-649-2828
Mailing Address - Fax:
Practice Address - Street 1:5005 N PIEDRAS ST
Practice Address - Street 2:ATTN DENTAC
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-742-5935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist