Provider Demographics
NPI:1396936795
Name:KIM, JEONG SUK (DDS, INC)
Entity type:Individual
Prefix:DR
First Name:JEONG SUK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS, INC
Other - Prefix:DR
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:408 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4505
Mailing Address - Country:US
Mailing Address - Phone:714-836-9999
Mailing Address - Fax:714-836-8496
Practice Address - Street 1:408 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4505
Practice Address - Country:US
Practice Address - Phone:714-836-9999
Practice Address - Fax:714-836-8496
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice