Provider Demographics
NPI:1730500893
Name:KIM, JENNIFER
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 BEACH BLVD
Mailing Address - Street 2:SUITE #109
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5300 BEACH BLVD
Practice Address - Street 2:SUITE #109
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-1250
Practice Address - Country:US
Practice Address - Phone:714-522-3734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist