Provider Demographics
NPI:1275654501
Name:KIM, ANNE SOOYUN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANNE
Middle Name:SOOYUN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19333 BEAR VALLEY RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-5148
Mailing Address - Country:US
Mailing Address - Phone:760-247-4155
Mailing Address - Fax:760-247-4955
Practice Address - Street 1:501 WASHINGTON ST STE 740
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2231
Practice Address - Country:US
Practice Address - Phone:619-296-2172
Practice Address - Fax:619-296-2178
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275654501Medicaid