Provider Demographics
NPI:1437258423
Name:KIM, JIN TAE (DDS)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:TAE
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 1:2605 EASTERN AVE
Mailing Address - Street 2:#2
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-6614
Mailing Address - Country:US
Mailing Address - Phone:916-481-3234
Mailing Address - Fax:916-481-4101
Practice Address - Street 1:2605 EASTERN AVE
Practice Address - Street 2:#2
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-6614
Practice Address - Country:US
Practice Address - Phone:916-481-3234
Practice Address - Fax:916-481-4101
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist