Provider Demographics
NPI:1942219969
Name:KIM, JUNGNAM E (DMD)
Entity Type:Individual
Prefix:
First Name:JUNGNAM
Middle Name:E
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6835 BROADWAY AVE
Mailing Address - Street 2:METROHEALTH BROADWAY HEALTH CENTER
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-1313
Mailing Address - Country:US
Mailing Address - Phone:216-957-1500
Mailing Address - Fax:
Practice Address - Street 1:6835 BROADWAY AVE
Practice Address - Street 2:METROHEALTH BROADWAY HEALTH CENTER
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-1313
Practice Address - Country:US
Practice Address - Phone:216-957-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30016344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0489163Medicaid