Provider Demographics
NPI:1003981440
Name:KIM, CALVIN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 N FAIRVIEW AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-6284
Mailing Address - Country:US
Mailing Address - Phone:805-692-5262
Mailing Address - Fax:805-692-1417
Practice Address - Street 1:271 N FAIRVIEW AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-6284
Practice Address - Country:US
Practice Address - Phone:805-692-5262
Practice Address - Fax:805-692-1417
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA49911OtherCALIFORNIA DENTAL LICENSE