Provider Demographics
NPI:1013402692
Name:KIM, JENNIFER PARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:PARK
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9127 HOGARTEN PARK
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2804
Mailing Address - Country:US
Mailing Address - Phone:571-247-3137
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST WEST, BLDG 1040
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78148
Practice Address - Country:US
Practice Address - Phone:210-652-1846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice