Active NPI
Jeanie Kim, D.D.S.
- Dentist
- San Rafael, CA
National Provider Identifier
1346427903
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 56312
- Practice address
- 411 4TH St
Suite C
San Rafael, CA 94901-5716 - Phone
- (415) 473-5454
- Fax
- (415) 473-5460
- NPI assigned
- Jan 25, 2008
- 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 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 56312 | CA | Primary |
Addresses
Primary practice location
411 4TH St
Suite C
San Rafael, CA 94901-5716
Mailing address
411 4TH St
Suite C
San Rafael, CA 94901-5716
Phone (415) 473-5454
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- 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 |
|---|---|---|---|---|
| I20211215001152 | CA | Order and Referring Only - Dentist | 3476944091 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 56312 | CA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1201219200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1201219200000",
"number": "1346427903",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "411 4TH ST",
"address_2": "SUITE C",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "949015716",
"telephone_number": "415-473-5454",
"fax_number": "415-473-5460"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "411 4TH ST",
"address_2": "SUITE C",
"city": "SAN RAFAEL",
"state": "CA",
"postal_code": "949015716",
"telephone_number": "415-473-5454",
"fax_number": "415-473-5460"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KIM",
"first_name": "JEANIE",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2008-01-25",
"last_updated": "2008-01-25",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "56312",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Rafael, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 25, 2008; 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.