Provider Demographics
NPI:1316019995
Name:KIM, JINSOO (DDS)
Entity Type:Individual
Prefix:MR
First Name:JINSOO
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 1:7505 VINEYARD TRL
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-2105
Mailing Address - Country:US
Mailing Address - Phone:253-394-4186
Mailing Address - Fax:888-502-2615
Practice Address - Street 1:4112 E RENNER RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2832
Practice Address - Country:US
Practice Address - Phone:972-480-0800
Practice Address - Fax:972-480-0900
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106181223G0001X
TX288561223D0004X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5051412Medicaid