Provider Demographics
NPI:1699025270
Name:KIM, HAE SUK (DDS)
Entity Type:Individual
Prefix:
First Name:HAE SUK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 S BEACH BLVD
Mailing Address - Street 2:STE G
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-1115
Mailing Address - Country:US
Mailing Address - Phone:562-448-3976
Mailing Address - Fax:
Practice Address - Street 1:1301 S BEACH BLVD
Practice Address - Street 2:STE G
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-1115
Practice Address - Country:US
Practice Address - Phone:562-448-3976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist