Provider Demographics
NPI:1689720740
Name:KIM, SOODONG (DDS)
Entity Type:Individual
Prefix:
First Name:SOODONG
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 1:2615 CANADA BLVD
Mailing Address - Street 2:#303
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2076
Mailing Address - Country:US
Mailing Address - Phone:818-247-2327
Mailing Address - Fax:909-886-3533
Practice Address - Street 1:1728 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-4418
Practice Address - Country:US
Practice Address - Phone:909-886-0087
Practice Address - Fax:909-886-3533
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA388591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB38859-01OtherCALIFORNIA HEALTHY FAMILY
CAG94047-01Medicaid