Provider Demographics
NPI:1508290495
Name:KIM, SO YEON (DDM)
Entity Type:Individual
Prefix:DR
First Name:SO YEON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 W MCFADDEN AVE STE E
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-2747
Mailing Address - Country:US
Mailing Address - Phone:714-835-8797
Mailing Address - Fax:
Practice Address - Street 1:2509 W MCFADDEN AVE STE E
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-2747
Practice Address - Country:US
Practice Address - Phone:714-835-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA546271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice