Provider Demographics
NPI:1568864262
Name:KIM, JIYEON J (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIYEON
Middle Name:J
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 WILSHIRE BLVD
Mailing Address - Street 2:APT 104
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3718
Mailing Address - Country:US
Mailing Address - Phone:424-777-5231
Mailing Address - Fax:
Practice Address - Street 1:2262 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-2532
Practice Address - Country:US
Practice Address - Phone:310-530-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA639631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice