Provider Demographics
NPI:1740357755
Name:KIM, JI S (DDS, PLLC)
Entity type:Individual
Prefix:
First Name:JI
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26750 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1529
Mailing Address - Country:US
Mailing Address - Phone:313-531-2000
Mailing Address - Fax:313-531-1063
Practice Address - Street 1:26750 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1529
Practice Address - Country:US
Practice Address - Phone:313-531-2000
Practice Address - Fax:313-531-1063
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010190351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124845452Medicaid