Healthcare Provider Details

I. General information

NPI: 1821821943
Provider Name (Legal Business Name): DR. JINAH KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JINAH LEE DMD

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PARKER DR # A
LAGRANGE GA
30240-6436
US

IV. Provider business mailing address

105 PARKER DR
LAGRANGE GA
30240-6436
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-3636
  • Fax:
Mailing address:
  • Phone: 706-884-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD.007456-C1
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN124259
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: