Provider Demographics
NPI:1548433279
Name:KIM, JENNIFER (DMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
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 1:3903 FAIR RIDGE DR STE 212
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2944
Mailing Address - Country:US
Mailing Address - Phone:703-865-6880
Mailing Address - Fax:703-865-6889
Practice Address - Street 1:3903 FAIR RIDGE DR STE 212
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2944
Practice Address - Country:US
Practice Address - Phone:703-865-6880
Practice Address - Fax:703-865-6889
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401412307122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist