Provider Demographics
NPI:1396962700
Name:KIM, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 OLD SPRING HOUSE LN
Mailing Address - Street 2:STE 315
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6215
Mailing Address - Country:US
Mailing Address - Phone:770-451-7041
Mailing Address - Fax:770-451-4886
Practice Address - Street 1:1720 OLD SPRING HOUSE LN
Practice Address - Street 2:STE 315
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6215
Practice Address - Country:US
Practice Address - Phone:770-451-7041
Practice Address - Fax:770-451-4886
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0134671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice