Provider Demographics
NPI:1417554411
Name:KIM, PETER KEEWAHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:KEEWAHN
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 1:1643 S SAN JACINTO AVE STE 100&101
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5181
Mailing Address - Country:US
Mailing Address - Phone:951-654-7744
Mailing Address - Fax:
Practice Address - Street 1:1643 S SAN JACINTO AVE STE 100&101
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5181
Practice Address - Country:US
Practice Address - Phone:951-654-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist