=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770378994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JYK DENTAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2025
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 PEACHTREE INDUSTRIAL BLVD STE 108
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-3004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-238-9383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3664 LOST OAK DR
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-4523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-704-7768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JINYEOP JASON KIM
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 404-704-7768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------