Provider Demographics
NPI:1043580079
Name:KIM, TAEYOUNG
Entity Type:Individual
Prefix:
First Name:TAEYOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 MICHELLE FL 2
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1008
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:15731 BERNARDO HEIGHTS PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3156
Practice Address - Country:US
Practice Address - Phone:858-674-6813
Practice Address - Fax:858-674-9792
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA606951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice