Provider Demographics
NPI:1710383724
Name:LIM, VIVIAN (DDS)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:LIM
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 1:411 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91755-1205
Mailing Address - Country:US
Mailing Address - Phone:617-797-2214
Mailing Address - Fax:
Practice Address - Street 1:7210 DAY CREEK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-7543
Practice Address - Country:US
Practice Address - Phone:909-803-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1059391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty