Provider Demographics
NPI:1417573312
Name:LIM, JIWON (DMD, MPH)
Entity type:Individual
Prefix:
First Name:JIWON
Middle Name:
Last Name:LIM
Suffix:
Gender:
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749112
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9112
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:
Practice Address - Street 1:1222 JEFFERSON PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3410
Practice Address - Country:US
Practice Address - Phone:434-924-1774
Practice Address - Fax:434-982-6417
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118671223G0001X
VA0411000075125Q00000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No125Q00000XDental ProvidersDentistOral Medicine