Provider Demographics
NPI:1467471987
Name:KIM, JEANNETTE K (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:K
Last Name:KIM
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 1:1012 COTTMAN AVE. 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111
Mailing Address - Country:US
Mailing Address - Phone:267-307-9691
Mailing Address - Fax:215-342-8409
Practice Address - Street 1:1012 COTTMAN AVE FL 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-3644
Practice Address - Country:US
Practice Address - Phone:267-307-9691
Practice Address - Fax:215-342-8409
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-031351-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice