Provider Demographics
NPI:1356851976
Name:IM, JINKYU
Entity Type:Individual
Prefix:
First Name:JINKYU
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N CENTRE AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-6303
Mailing Address - Country:US
Mailing Address - Phone:347-536-9017
Mailing Address - Fax:
Practice Address - Street 1:100 N CENTRE AVE STE 402
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-6303
Practice Address - Country:US
Practice Address - Phone:347-536-9017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33458122300000X
NY060981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist