Provider Demographics
NPI:1790977346
Name:LIM, JILLIAN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 WARMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4534
Mailing Address - Country:US
Mailing Address - Phone:917-650-0304
Mailing Address - Fax:
Practice Address - Street 1:2331 WARMOUTH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-4534
Practice Address - Country:US
Practice Address - Phone:917-650-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04444811223X0400X
CADDS1010701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01516632Medicaid