Provider Demographics
NPI:1073708202
Name:SAMUEL KIM DDS INC
Entity Type:Organization
Organization Name:SAMUEL KIM DDS INC
Other - Org Name:APPLE VALLEY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-247-6007
Mailing Address - Street 1:21580 BEAR VALLEY RD STE B2-2
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-7200
Mailing Address - Country:US
Mailing Address - Phone:760-247-6007
Mailing Address - Fax:
Practice Address - Street 1:21580 BEAR VALLEY RD STE B2-2
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-7200
Practice Address - Country:US
Practice Address - Phone:760-247-6007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty