Provider Demographics
NPI:1780817007
Name:KIM, MICHELLE YOUNGEUN (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:YOUNGEUN
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 1:29 BIRCH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-1430
Mailing Address - Country:US
Mailing Address - Phone:909-855-7646
Mailing Address - Fax:
Practice Address - Street 1:29 BIRCH ST STE 4
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-1430
Practice Address - Country:US
Practice Address - Phone:909-855-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18552441223G0001X
CA62417122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice