Provider Demographics
NPI:1114034139
Name:KIM, CHANGSOOK (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHANGSOOK
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 1:1755 E HUNTINGTON DR
Mailing Address - Street 2:#101
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010
Mailing Address - Country:US
Mailing Address - Phone:626-357-9909
Mailing Address - Fax:626-358-7245
Practice Address - Street 1:1755 E HUNTINGTON DR
Practice Address - Street 2:#101
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010
Practice Address - Country:US
Practice Address - Phone:626-357-9909
Practice Address - Fax:626-358-7245
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist