Provider Demographics
NPI:1689016255
Name:KIM, AILEEN (DDS, MS)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 S GRAND AVE APT 706
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-2169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:933 S SUNSET AVE
Practice Address - Street 2:208
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3410
Practice Address - Country:US
Practice Address - Phone:626-483-7714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA613071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics