Provider Demographics
NPI:1962842575
Name:LIM, RICHARD S (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:S
Last Name:LIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11834 BRYANT ST STE 102
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3848
Mailing Address - Country:US
Mailing Address - Phone:909-797-8090
Mailing Address - Fax:909-797-8090
Practice Address - Street 1:11834 BRYANT ST STE 102
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-3848
Practice Address - Country:US
Practice Address - Phone:909-079-7809
Practice Address - Fax:909-797-8090
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1497146872Medicaid