Healthcare Provider Details

I. General information

NPI: 1659885523
Provider Name (Legal Business Name): BSJC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

692 N MARINE CORPS DR STE 301
TAMUNING GU
96913-4454
US

IV. Provider business mailing address

692 N MARINE CORPS DR STE 301
TAMUNING GU
96913-4454
US

V. Phone/Fax

Practice location:
  • Phone: 671-300-3221
  • Fax: 671-300-3223
Mailing address:
  • Phone: 671-300-3221
  • Fax: 671-300-3223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD1014
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JONGSUNG KIM
Title or Position: CEO
Credential: DDS
Phone: 671-300-3221