Provider Demographics
NPI:1053667832
Name:KIM, AUDREY (DDS)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
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 1:17775 CALLE GRANADA
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-2992
Mailing Address - Country:US
Mailing Address - Phone:716-374-3273
Mailing Address - Fax:
Practice Address - Street 1:930 SUNNYSLOPE RD STE B3
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5616
Practice Address - Country:US
Practice Address - Phone:831-647-4627
Practice Address - Fax:831-637-7017
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61519122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist