Provider Demographics
NPI:1285287110
Name:KIM, JAE EUN (DMD)
Entity type:Individual
Prefix:
First Name:JAE EUN
Middle Name:
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 1:8819 WHITTIER BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-2673
Mailing Address - Country:US
Mailing Address - Phone:562-699-1000
Mailing Address - Fax:
Practice Address - Street 1:8819 WHITTIER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2673
Practice Address - Country:US
Practice Address - Phone:562-699-1000
Practice Address - Fax:562-699-1099
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1040681223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA104068OtherAVAILITY
CA104068Medicaid