Basic Information
| Provider Information | |||||||||
| NPI: | 1548632607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JAE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1955 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910013037 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 144 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066101604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034377561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 65151 | CA | N | Dental Providers | Dentist | General Practice | 1223X0400X | 65151 | CA | N | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223X0400X | 12130 | CT | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.