Provider Demographics
NPI:1083190748
Name:KIM, JEFFREY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 CAZADOR ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-3406
Mailing Address - Country:US
Mailing Address - Phone:213-598-8903
Mailing Address - Fax:
Practice Address - Street 1:4200 CHINO HILLS PKWY STE 880
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5831
Practice Address - Country:US
Practice Address - Phone:909-393-5456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102552122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist