Provider Demographics
NPI:1659449791
Name:KIM, STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7841 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2422
Mailing Address - Country:US
Mailing Address - Phone:714-739-7173
Mailing Address - Fax:714-739-7174
Practice Address - Street 1:7841 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2422
Practice Address - Country:US
Practice Address - Phone:714-739-7173
Practice Address - Fax:714-739-7174
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05150611223G0001X
CA582311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02664253Medicaid