Provider Demographics
NPI:1609499979
Name:JAESUNG KIM DMD INC
Entity Type:Organization
Organization Name:JAESUNG KIM DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAESUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:213-616-8119
Mailing Address - Street 1:3534 HASTINGS DR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92010-7040
Mailing Address - Country:US
Mailing Address - Phone:213-616-8119
Mailing Address - Fax:
Practice Address - Street 1:1520 N EL CAMINO REAL STE 5
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5957
Practice Address - Country:US
Practice Address - Phone:213-616-8119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty