Provider Demographics
NPI:1750459988
Name:KIM, JERRY CHONGMIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:CHONGMIN
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10243 BRITTENFORD DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-1867
Mailing Address - Country:US
Mailing Address - Phone:703-716-0769
Mailing Address - Fax:
Practice Address - Street 1:8622 LEE HWY STE A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2148
Practice Address - Country:US
Practice Address - Phone:703-876-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010072211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice