Provider Demographics
NPI:1811413594
Name:KIM, CHRIS Y (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:CHRIS
Other - Middle Name:YONGHYUN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:16213 STAR CREST WAY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1472
Mailing Address - Country:US
Mailing Address - Phone:909-275-1626
Mailing Address - Fax:
Practice Address - Street 1:8400 OSUNA RD NE STE 5A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2072
Practice Address - Country:US
Practice Address - Phone:505-884-1989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD47811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice