Provider Demographics
NPI:1629324439
Name:KIM, SOPHIA (DDS)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SEULKI
Other - Middle Name:
Other - Last Name:YANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2120 S GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4802
Mailing Address - Country:US
Mailing Address - Phone:909-809-8873
Mailing Address - Fax:
Practice Address - Street 1:126 AVOCADO AVE STE 202
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-940-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist