Provider Demographics
NPI:1528804689
Name:KIM, JAEWOO
Entity type:Individual
Prefix:
First Name:JAEWOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 W MARKET ST
Practice Address - Street 2:
Practice Address - City:HALLAM
Practice Address - State:PA
Practice Address - Zip Code:17406-1024
Practice Address - Country:US
Practice Address - Phone:231-942-2827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0446701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice