Healthcare Provider Details

I. General information

NPI: 1902586266
Provider Name (Legal Business Name): JIHANG KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date: 02/28/2024
Reactivation Date: 08/12/2026

III. Provider practice location address

51 HAMILTON ST
WORCESTER MA
01604-2203
US

IV. Provider business mailing address

125 GUEST ST APT 603
BOSTON MA
02135-2084
US

V. Phone/Fax

Practice location:
  • Phone: 774-375-0090
  • Fax:
Mailing address:
  • Phone: 917-224-5373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10001452
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: