Provider Demographics
NPI:1174612626
Name:KIM, JUNG B (DMD)
Entity type:Individual
Prefix:DR
First Name:JUNG
Middle Name:B
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 W 13TH STREET
Mailing Address - Street 2:SUITE 7
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-4054
Mailing Address - Country:US
Mailing Address - Phone:302-652-3556
Mailing Address - Fax:302-654-8088
Practice Address - Street 1:1815 W 13TH STREET
Practice Address - Street 2:SUITE 7
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806
Practice Address - Country:US
Practice Address - Phone:302-652-3556
Practice Address - Fax:302-654-8088
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE10491223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001186808Medicaid
263203OtherUNITED CONCORDIA