Provider Demographics
NPI:1053091249
Name:KIM, JIHOON (DDS)
Entity type:Individual
Prefix:
First Name:JIHOON
Middle Name:
Last Name:KIM
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 1:926 RAINIER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4000
Mailing Address - Country:US
Mailing Address - Phone:801-815-7772
Mailing Address - Fax:
Practice Address - Street 1:2927 STUARTS DRAFT HWY STE 105
Practice Address - Street 2:
Practice Address - City:STUARTS DRAFT
Practice Address - State:VA
Practice Address - Zip Code:24477-2796
Practice Address - Country:US
Practice Address - Phone:540-414-8423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014189151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice