Provider Demographics
NPI:1326181785
Name:IM, KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:IM
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 1:601 E WHITTIER BLVD
Mailing Address - Street 2:#103
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-3972
Mailing Address - Country:US
Mailing Address - Phone:562-905-2081
Mailing Address - Fax:562-905-2086
Practice Address - Street 1:601 E WHITTIER BLVD
Practice Address - Street 2:#103
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-3972
Practice Address - Country:US
Practice Address - Phone:562-905-2081
Practice Address - Fax:562-905-2086
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA354081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice