Provider Demographics
NPI:1912216854
Name:KIM, JAE HO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:HO
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 1:289 IRELAND AVE
Mailing Address - Street 2:ORAL SURGERY, HOSPITAL DENTAL CLINIC
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5111
Mailing Address - Country:US
Mailing Address - Phone:857-919-4334
Mailing Address - Fax:
Practice Address - Street 1:5906 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-1935
Practice Address - Country:US
Practice Address - Phone:857-919-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY95541223S0112X
WV40351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery