Provider Demographics
NPI:1710448766
Name:KIM, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12626 CROSSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2671
Mailing Address - Country:US
Mailing Address - Phone:562-565-7021
Mailing Address - Fax:
Practice Address - Street 1:29950 HAUN RD STE 302
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92586-6527
Practice Address - Country:US
Practice Address - Phone:951-679-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1073351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry