Provider Demographics
NPI:1588189179
Name:KIM, HAYEUN
Entity Type:Individual
Prefix:
First Name:HAYEUN
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 1:341 S BERENDO ST APT 211
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2071
Mailing Address - Country:US
Mailing Address - Phone:213-435-4762
Mailing Address - Fax:
Practice Address - Street 1:2805 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-2023
Practice Address - Country:US
Practice Address - Phone:323-846-8443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1018341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice