Provider Demographics
NPI:1093263691
Name:KIM, MELANIE MIDORI (DMD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:MIDORI
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3381 BASS LAKE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-6634
Mailing Address - Country:US
Mailing Address - Phone:916-545-9449
Mailing Address - Fax:916-604-4313
Practice Address - Street 1:3381 BASS LAKE RD STE 140
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-6634
Practice Address - Country:US
Practice Address - Phone:916-545-9449
Practice Address - Fax:916-604-4313
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6814122300000X
CA103560122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist