Provider Demographics
NPI:1568936763
Name:KIM, JISU (DDS)
Entity type:Individual
Prefix:
First Name:JISU
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 N KING ST STE 207
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4584
Mailing Address - Country:US
Mailing Address - Phone:808-499-7924
Mailing Address - Fax:
Practice Address - Street 1:1070 N KING ST STE 207
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4584
Practice Address - Country:US
Practice Address - Phone:808-499-7924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60997067122300000X
TX35909122300000X
HIDT-2882122300000X
PADS040530122300000X
CT12444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist