Provider Demographics
NPI:1801920921
Name:KIM, JANG WOOK (DDS)
Entity type:Individual
Prefix:MR
First Name:JANG WOOK
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 1:5455 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #850
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036
Mailing Address - Country:US
Mailing Address - Phone:323-930-4600
Mailing Address - Fax:323-930-4604
Practice Address - Street 1:5455 WILSHIRE BLVD
Practice Address - Street 2:SUITE #850
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036
Practice Address - Country:US
Practice Address - Phone:323-930-4600
Practice Address - Fax:323-930-4604
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD50150011223G0001X
CA50150122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD5015001Medicaid
CAD5015001Medicaid