Provider Demographics
NPI:1871147447
Name:KIM, JENNIFER (DDS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MIN
Other - Middle Name:GI
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8621 GEORGIA AVE APT 1403
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3885
Mailing Address - Country:US
Mailing Address - Phone:678-979-8323
Mailing Address - Fax:
Practice Address - Street 1:6428 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-2910
Practice Address - Country:US
Practice Address - Phone:202-723-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN1002029122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCDEN1002029Medicaid