Provider Demographics
NPI:1265684161
Name:KIM, YONG SOO (DDS)
Entity Type:Individual
Prefix:DR
First Name:YONG
Middle Name:SOO
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:SHUTTLEWORTH DENTAL CLINIC
Mailing Address - Street 2:171 INNER LOOP RD.
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-5080
Mailing Address - Country:US
Mailing Address - Phone:760-380-3166
Mailing Address - Fax:
Practice Address - Street 1:171 INNER LOOP RD
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:760-380-3166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT71130061223G0001X
UT7113006-89031223G0001X
UT7113006-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice