Provider Demographics
NPI:1194238956
Name:KIM, JAYUN JOANNA (DMD)
Entity type:Individual
Prefix:DR
First Name:JAYUN
Middle Name:JOANNA
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 1:663 TRAIL SIDE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-7884
Mailing Address - Country:US
Mailing Address - Phone:502-753-9941
Mailing Address - Fax:
Practice Address - Street 1:4920 TX-121 #200
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056
Practice Address - Country:US
Practice Address - Phone:972-300-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10038122300000X, 1223G0001X
TX38358122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100499030Medicaid