Provider Demographics
NPI:1841714078
Name:KIM, JI SEOK (DMD)
Entity type:Individual
Prefix:
First Name:JI SEOK
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6523 ESCENA BLVD UNIT 3100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-4280
Mailing Address - Country:US
Mailing Address - Phone:267-475-2539
Mailing Address - Fax:
Practice Address - Street 1:7033 GREENVILLE AVE STE 102
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5116
Practice Address - Country:US
Practice Address - Phone:214-233-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-30
Last Update Date:2017-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33325122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist