Provider Demographics
NPI:1598927105
Name:IM, PATRICK H (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:H
Last Name:IM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:PATRICK
Other - Middle Name:H
Other - Last Name:IM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:15230 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-8107
Mailing Address - Country:US
Mailing Address - Phone:707-995-4540
Mailing Address - Fax:707-994-2401
Practice Address - Street 1:9560 LEGACY OAKS DR
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-4869
Practice Address - Country:US
Practice Address - Phone:706-264-9441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011603122300000X
CA42663122300000X
TN9219122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist