Provider Demographics
NPI:1124651906
Name:KIM, JANE MINJEE (DMD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:MINJEE
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 BARTON RD APT 4114
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5371
Mailing Address - Country:US
Mailing Address - Phone:909-557-3403
Mailing Address - Fax:
Practice Address - Street 1:1601 BARTON RD APT 4114
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5371
Practice Address - Country:US
Practice Address - Phone:909-557-3403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104798122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist