Provider Demographics
NPI:1215274865
Name:KIM, JAE S (DDS)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 N FILLMORE ST
Mailing Address - Street 2:A
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-6701
Mailing Address - Country:US
Mailing Address - Phone:703-243-7744
Mailing Address - Fax:
Practice Address - Street 1:1025 N FILLMORE ST
Practice Address - Street 2:A
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-6701
Practice Address - Country:US
Practice Address - Phone:703-243-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61791122300000X
VA04014153081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist