Provider Demographics
NPI:1407547151
Name:KIM, JASON MINJE (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MINJE
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 1:161 W WISCONSIN AVE APT 214
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2605
Mailing Address - Country:US
Mailing Address - Phone:317-965-9259
Mailing Address - Fax:
Practice Address - Street 1:2100 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-1641
Practice Address - Country:US
Practice Address - Phone:317-965-9259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI6001179-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty