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General NPI Number Information
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NPI Number | 1912216854
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Entity Type | Individual
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Provider Name | JAE HO KIM DDS
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Gender | Male
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Dates
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Enumeration Date | 09/27/2010
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Last Update Date | 11/19/2015
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Provider Practice Location Address
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Address Line | 5906 BARDSTOWN RD
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City | LOUISVILLE
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State | KY
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Zip | 40291-1935
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Country | US
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Telephone | 857-919-4334
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Fax |
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Provider Business Mailing Address
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Address Line | 289 IRELAND AVE ORAL SURGERY, HOSPITAL DENTAL CLINIC
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City | FORT KNOX
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State | KY
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Zip | 40121-5111
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Country | US
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Telephone | 857-919-4334
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 9554
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License Number State | KY
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