Provider Demographics
NPI:1023090347
Name:IM, JIM J (DDS)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:J
Last Name:IM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9320 VAN GUARD CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-8291
Mailing Address - Country:US
Mailing Address - Phone:714-833-0536
Mailing Address - Fax:
Practice Address - Street 1:79TH DS
Practice Address - Street 2:BLDG 1601
Practice Address - City:ANDREWS AFB
Practice Address - State:MD
Practice Address - Zip Code:20762
Practice Address - Country:US
Practice Address - Phone:240-857-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist