Provider Demographics
NPI:1063575710
Name:LIM, JAE S
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:S
Last Name:LIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 S PARK VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-6975
Mailing Address - Country:US
Mailing Address - Phone:408-946-9494
Mailing Address - Fax:408-942-0012
Practice Address - Street 1:1123 S PARK VICTORIA DR
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6975
Practice Address - Country:US
Practice Address - Phone:408-946-9494
Practice Address - Fax:408-942-0012
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice