Provider Demographics
NPI:1790793750
Name:KIM, JASON (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
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 1:144-48 ROOSEVELT AVE
Mailing Address - Street 2:STE MD-B
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354
Mailing Address - Country:US
Mailing Address - Phone:718-886-4545
Mailing Address - Fax:718-886-0029
Practice Address - Street 1:144-48 ROOSEVELT AVE
Practice Address - Street 2:STE MD-B
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-886-4545
Practice Address - Fax:718-886-0029
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047030122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist