Provider Demographics
NPI:1306002480
Name:KIM, JIN KOO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIN
Middle Name:KOO
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DEMARCO RD
Mailing Address - Street 2:
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-2019
Mailing Address - Country:US
Mailing Address - Phone:339-221-3692
Mailing Address - Fax:
Practice Address - Street 1:19 DEMARCO RD
Practice Address - Street 2:
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-2019
Practice Address - Country:US
Practice Address - Phone:339-221-3692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice