Provider Demographics
NPI:1467123331
Name:KIM, CHAE JIN (DDS)
Entity Type:Individual
Prefix:
First Name:CHAE
Middle Name:JIN
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 1:16570 FERN HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-3708
Mailing Address - Country:US
Mailing Address - Phone:949-677-1348
Mailing Address - Fax:
Practice Address - Street 1:3760 W MCFADDEN AVE STE D
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-1392
Practice Address - Country:US
Practice Address - Phone:657-231-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1069841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice