Basic Information
| Provider Information | |||||||||
| NPI: | 1235534157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 428 GRAND AVENUE PARKWAY | ||||||||
| Address2: | SUITE150 | ||||||||
| City: | PFLUGERVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126492828 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | ATTN DENTAC | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157425935 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30748 | TX | Y | Dental Providers | Dentist |
No ID Information.