Provider Demographics
NPI:1003531104
Name:KIM, HA EUN (DDS)
Entity Type:Individual
Prefix:
First Name:HA
Middle Name:EUN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11770 RANDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4188
Mailing Address - Country:US
Mailing Address - Phone:909-488-6723
Mailing Address - Fax:
Practice Address - Street 1:12625 FREDERICK ST STE F4
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5234
Practice Address - Country:US
Practice Address - Phone:951-697-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist