Provider Demographics
NPI:1740431451
Name:KIM, EDMOND L (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:L
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:Y
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OFFICE MANAGER
Mailing Address - Street 1:4909 S COAST HWY STE 8
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97366-9654
Mailing Address - Country:US
Mailing Address - Phone:541-867-3755
Mailing Address - Fax:541-867-3756
Practice Address - Street 1:4909 S COAST HWY STE 8
Practice Address - Street 2:
Practice Address - City:SOUTH BEACH
Practice Address - State:OR
Practice Address - Zip Code:97366-9654
Practice Address - Country:US
Practice Address - Phone:541-867-3755
Practice Address - Fax:541-867-3756
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist