Provider Demographics
NPI:1174294649
Name:KIM, YOUNGSEOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:YOUNGSEOB
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4146 STURGEON CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2145
Mailing Address - Country:US
Mailing Address - Phone:858-717-7497
Mailing Address - Fax:
Practice Address - Street 1:5820 OBERLIN DR STE 109
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3743
Practice Address - Country:US
Practice Address - Phone:858-550-9688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice