Provider Demographics
NPI:1508038308
Name:JAMES KIM DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:JAMES KIM DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-866-0606
Mailing Address - Street 1:PO BOX 6951
Mailing Address - Street 2:42002 FOX FARM RD. #101
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-6951
Mailing Address - Country:US
Mailing Address - Phone:909-866-0606
Mailing Address - Fax:909-866-5546
Practice Address - Street 1:42002 FOX FARM RD.
Practice Address - Street 2:#101
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-0606
Practice Address - Fax:909-866-5546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA479171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty