Provider Demographics
NPI:1639557739
Name:KIM, HYUNJI (DMD)
Entity Type:Individual
Prefix:
First Name:HYUNJI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 S GRAND AVE APT 1216
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-4388
Mailing Address - Country:US
Mailing Address - Phone:913-306-1281
Mailing Address - Fax:
Practice Address - Street 1:1120 S GRAND AVE APT 1216
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-4388
Practice Address - Country:US
Practice Address - Phone:913-306-1281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857629122300000X
CA1058481223G0001X
CADDS1058481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1639557739OtherNPI