Provider Demographics
NPI:1336746676
Name:KIM, MIN JEONG (DDS)
Entity type:Individual
Prefix:
First Name:MIN JEONG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 W EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-6106
Mailing Address - Country:US
Mailing Address - Phone:617-331-5360
Mailing Address - Fax:
Practice Address - Street 1:970 W EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-6106
Practice Address - Country:US
Practice Address - Phone:650-282-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1056721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice