=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053981407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAKE KIM DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2021
-----------------------------------------------------
Last Update Date | 11/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 507 JEFFERSON LN
-----------------------------------------------------
City | LAKE DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75065-3489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-477-4659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 JEFFERSON LN
-----------------------------------------------------
City | LAKE DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75065-3489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-477-4659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 39478
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------