Provider Demographics
NPI:1356641922
Name:KIM, GRACE MIJIN (DDS)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MIJIN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 S BARRANCA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-5421
Mailing Address - Country:US
Mailing Address - Phone:626-339-4600
Mailing Address - Fax:626-339-4099
Practice Address - Street 1:1770 S BARRANCA AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-5421
Practice Address - Country:US
Practice Address - Phone:626-339-4600
Practice Address - Fax:626-339-4099
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA584451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice