Active NPI
Jennifer Dasol Kim, DDS
- Pediatric Dentistry
- Fairlawn, OH
National Provider Identifier
1215513221
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 30.026918
- Practice address
- 3523 Commercial Dr
Fairlawn, OH 44333-5107 - Phone
- (330) 577-5774
- NPI assigned
- Mar 20, 2021
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 30.026918 | OH | Primary |
| Student in an Organized Health Care Education/Training Program | 390200000X |
Addresses
Primary practice location
3523 Commercial Dr
Fairlawn, OH 44333-5107
Mailing address
15 Stridesham CT
Baltimore, MD 21209-5301
Phone (410) 978-1004
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MD
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20210826000058 | MD | Order and Referring Only - Dentist | 5991100158 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30.026918 | OH | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1616198400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1691366400000",
"number": "1215513221",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "15 STRIDESHAM CT",
"city": "BALTIMORE",
"state": "MD",
"postal_code": "212095301",
"telephone_number": "410-978-1004"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3523 COMMERCIAL DR",
"city": "FAIRLAWN",
"state": "OH",
"postal_code": "443335107",
"telephone_number": "330-577-5774"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KIM",
"first_name": "JENNIFER",
"middle_name": "DASOL",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2021-03-20",
"last_updated": "2023-08-07",
"certification_date": "2023-08-05",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "OH",
"license": "30.026918",
"primary": true
},
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fairlawn, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.