Provider Demographics
NPI:1043814551
Name:KIM, JAE HEE
Entity type:Individual
Prefix:
First Name:JAE HEE
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 1:1009 SADDLE TREE TRL
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4492
Mailing Address - Country:US
Mailing Address - Phone:972-822-4689
Mailing Address - Fax:
Practice Address - Street 1:307 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-3549
Practice Address - Country:US
Practice Address - Phone:956-380-2482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist