Individual
JEFFREY MARK KIM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
4570 S CLYDE MORRIS BLVD, SUITE 1, PORT ORANGE, FL 32129-5401
(386) 322-4867
(386) 322-3899
Mailing address
4570 S CLYDE MORRIS BLVD, SUITE 1, PORT ORANGE, FL 32129-5401
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
Primary
DN13917
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DN13917
STATE LICENSE NUMBER
FL
Enumeration date
01/05/2012
Last updated
01/05/2012
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