Provider Demographics
NPI:1689600173
Name:MCKIM, MICHAEL JERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JERRY
Last Name:MCKIM
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 1:1400 SANTA RITA RD
Mailing Address - Street 2:SUITE L
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-5666
Mailing Address - Country:US
Mailing Address - Phone:925-846-2231
Mailing Address - Fax:925-846-8663
Practice Address - Street 1:1400 SANTA RITA RD
Practice Address - Street 2:SUITE L
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-5666
Practice Address - Country:US
Practice Address - Phone:925-846-2231
Practice Address - Fax:925-846-8663
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40678122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist