Provider Demographics
NPI:1629113857
Name:KIM, MICHELLE KYONGAH (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KYONGAH
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:KYONGAH
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2245 E COLORADO BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-449-3367
Mailing Address - Fax:626-449-3376
Practice Address - Street 1:2245 E COLORADO BLVD
Practice Address - Street 2:STE 201
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-449-3367
Practice Address - Fax:626-449-3376
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA42670OtherMEDICAL/DENTICAL