Provider Demographics
NPI:1346782018
Name:KIM, JI SUN
Entity Type:Individual
Prefix:
First Name:JI SUN
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 1:3823 MAHER MNR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-5979
Mailing Address - Country:US
Mailing Address - Phone:919-450-7550
Mailing Address - Fax:
Practice Address - Street 1:3823 MAHER MNR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-5979
Practice Address - Country:US
Practice Address - Phone:919-450-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-13
Last Update Date:2016-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014152191223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics