Provider Demographics
NPI:1417014655
Name:KIM, BRYAN BUMSOO (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:BUMSOO
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:BUMSOO
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3030 W. 8TH ST.
Mailing Address - Street 2:#305
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005
Mailing Address - Country:US
Mailing Address - Phone:213-389-0937
Mailing Address - Fax:213-389-1937
Practice Address - Street 1:3030 W 8TH ST
Practice Address - Street 2:#305
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1812
Practice Address - Country:US
Practice Address - Phone:213-389-0937
Practice Address - Fax:213-389-1937
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA260891OtherUNITED CONCORDIA
CAB32333-01OtherDELTA HEALTHY FAMILY
CAB32333-01OtherDELTA HEALTHY FAMILY