Provider Demographics
NPI:1184830309
Name:KIM, IN YOUNG (DDS)
Entity Type:Individual
Prefix:
First Name:IN
Middle Name:YOUNG
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 1:9710 GARDEN GROVE BLVD
Mailing Address - Street 2:B
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1644
Mailing Address - Country:US
Mailing Address - Phone:714-539-5013
Mailing Address - Fax:
Practice Address - Street 1:9710 GARDEN GROVE BLVD
Practice Address - Street 2:B
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1644
Practice Address - Country:US
Practice Address - Phone:714-539-5013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA270091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2700902OtherMEDICAL
CAB2700902OtherDENTICAL