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General NPI Number Information
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NPI Number | 1629198551
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Entity Type | Organization
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Legal Business Name | J. KIM PERIODONTICS, LLC
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 09/28/2007
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Provider Practice Location Address
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Address Line | 4570 S CLYDE MORRIS BLVD SUITE 1
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City | PORT ORANGE
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State | FL
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Zip | 32129-5401
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Country | US
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Telephone | 386-322-4867
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Fax |
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Provider Business Mailing Address
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Address Line | 4570 S CLYDE MORRIS BLVD SUITE 1
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City | PORT ORANGE
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State | FL
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Zip | 32129-5401
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Country | US
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Telephone | 386-322-4867
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFFREY M KIM
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Credential | DDS
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Telephone | 386-322-4867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN13917
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License Number State | FL
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