Healthcare Provider Details

I. General information

NPI: 1427874536
Provider Name (Legal Business Name): JIN YONG SIM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 ROSWELL RD STE 56
MARIETTA GA
30062-8828
US

IV. Provider business mailing address

3535 ROSWELL RD STE 56
MARIETTA GA
30062-8828
US

V. Phone/Fax

Practice location:
  • Phone: 678-996-6949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN124161
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: