Provider Demographics
NPI:1578778825
Name:KIM, JEONG DOO (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:JEONG
Middle Name:DOO
Last Name:KIM
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20505 VIA TENORIO
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-3239
Mailing Address - Country:US
Mailing Address - Phone:310-713-5159
Mailing Address - Fax:
Practice Address - Street 1:4000 TYLER ST STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3458
Practice Address - Country:US
Practice Address - Phone:951-687-4460
Practice Address - Fax:951-687-7448
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA506221223S0112X
CAA1022201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery