Provider Demographics
NPI:1275772063
Name:KIM, HA JUNG
Entity Type:Individual
Prefix:
First Name:HA JUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 5TH ST STE H
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:CA
Mailing Address - Zip Code:93926-9437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:851 5TH ST STE H
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:CA
Practice Address - Zip Code:93926-9437
Practice Address - Country:US
Practice Address - Phone:831-240-0865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54710122300000X, 1223G0001X
OH30-022952122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice