Provider Demographics
NPI:1780207993
Name:KIM, JENNIFER SUJI (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUJI
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 ANDERSON AVE APT 7A
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 W ALLENDALE AVE
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:NJ
Practice Address - Zip Code:07401-1739
Practice Address - Country:US
Practice Address - Phone:201-760-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2022-06-28
Deactivation Date:2021-08-01
Deactivation Code:
Reactivation Date:2021-08-20
Provider Licenses
StateLicense IDTaxonomies
NJ22DI028357001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice