Provider Demographics
NPI:1851027254
Name:KIM, KI BUM
Entity Type:Individual
Prefix:DR
First Name:KI BUM
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:KB
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:6726 LIMONITE CT
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-5202
Mailing Address - Country:US
Mailing Address - Phone:760-809-5061
Mailing Address - Fax:
Practice Address - Street 1:6726 LIMONITE CT
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-5202
Practice Address - Country:US
Practice Address - Phone:760-809-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033884122300000X
WADE61172402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist