Provider Demographics
NPI:1417573312
Name:LIM, JIWON (DMD)
Entity Type:Individual
Prefix:
First Name:JIWON
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 MARITIME LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-1630
Mailing Address - Country:US
Mailing Address - Phone:336-692-2211
Mailing Address - Fax:
Practice Address - Street 1:10 CENTER DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-3825
Practice Address - Country:US
Practice Address - Phone:301-827-7759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118671223G0001X
MI29510008071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice