Healthcare Provider Details

I. General information

NPI: 1013713577
Provider Name (Legal Business Name): JI WON KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MILK ST STE 120
METHUEN MA
01844-4600
US

IV. Provider business mailing address

100 MILK ST STE 120
METHUEN MA
01844-4600
US

V. Phone/Fax

Practice location:
  • Phone: 978-688-4441
  • Fax:
Mailing address:
  • Phone: 978-688-4441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN10001446
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: