Healthcare Provider Details

I. General information

NPI: 1497690002
Provider Name (Legal Business Name): JINSIL ALEXIS KIM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 E 10600 S STE 104
SANDY UT
84070-4124
US

IV. Provider business mailing address

65 E 10600 S STE 104
SANDY UT
84070-4124
US

V. Phone/Fax

Practice location:
  • Phone: 801-335-6465
  • Fax:
Mailing address:
  • Phone: 801-335-6465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14281626-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: