Provider Demographics
NPI:1053672022
Name:KIM, JAE SEON (DDS)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:SEON
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 1:1430 JOHN WESLEY GILBERT DRIVE
Mailing Address - Street 2:GC-1024
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-1001
Mailing Address - Country:US
Mailing Address - Phone:706-721-9633
Mailing Address - Fax:706-723-0266
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:GC-1024
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1001
Practice Address - Country:US
Practice Address - Phone:706-721-9633
Practice Address - Fax:706-723-0266
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNF0003661223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics