Provider Demographics
NPI:1750055745
Name:KIM, KELLY MIN AH
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MIN AH
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 1:42500 WASHINGTON ST
Mailing Address - Street 2:STE 101
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42500 WASHINGTON ST
Practice Address - Street 2:STE 101
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211
Practice Address - Country:US
Practice Address - Phone:551-482-0276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106479122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist