Provider Demographics
NPI:1467913863
Name:KIM, JASON DONGHYUN
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DONGHYUN
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DONG HYUN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 MOUNTAIN AVE # SC13
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3414
Mailing Address - Country:US
Mailing Address - Phone:973-506-0159
Mailing Address - Fax:
Practice Address - Street 1:542 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-1532
Practice Address - Country:US
Practice Address - Phone:201-623-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02806400122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program