Provider Demographics
NPI:1528378700
Name:KIM, JUNGWON (DDS)
Entity Type:Individual
Prefix:
First Name:JUNGWON
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 SHENLEY PARK LN
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4942
Mailing Address - Country:US
Mailing Address - Phone:404-717-9122
Mailing Address - Fax:
Practice Address - Street 1:350 TOWN CENTER AVE
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6914
Practice Address - Country:US
Practice Address - Phone:833-210-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA607352981223P0221X
GA122581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry