Provider Demographics
NPI:1528600640
Name:KIM, MINGYEONG
Entity Type:Individual
Prefix:
First Name:MINGYEONG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20311 STEVENS CREEK BLVD STE 1B
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-2230
Mailing Address - Country:US
Mailing Address - Phone:406-446-1111
Mailing Address - Fax:
Practice Address - Street 1:20311 STEVENS CREEK BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2230
Practice Address - Country:US
Practice Address - Phone:406-446-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA351480126900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126900000XDental ProvidersDental Laboratory Technician