Provider Demographics
NPI:1649946203
Name:KIM, JUSTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 4TH ST UNIT 105
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-1604
Mailing Address - Country:US
Mailing Address - Phone:323-386-1236
Mailing Address - Fax:
Practice Address - Street 1:1150 IMOLA AVE
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-4237
Practice Address - Country:US
Practice Address - Phone:707-224-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106581122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist