Provider Demographics
NPI:1902463821
Name:KIM, JIN SEOK
Entity type:Individual
Prefix:
First Name:JIN SEOK
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 1:350 N CLARK ST STE 600
Mailing Address - Street 2:C/O KOS SERVICES, ATTN: HR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 N CLARK ST STE 600
Practice Address - Street 2:C/O KOS SERVICES, ATTN: HR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4782
Practice Address - Country:US
Practice Address - Phone:312-274-0308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1039321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice