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General NPI Number Information
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NPI Number | 1982974135
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Entity Type | Individual
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Provider Name | JEFFREY MARK KIM DDS
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Gender | Male
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Dates
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Enumeration Date | 01/05/2012
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Last Update Date | 01/05/2012
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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 | 386-322-3899
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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 |
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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 | 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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