Provider Demographics
NPI:1982867917
Name:IM, TERRY I (DDS)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:IM
Suffix:I
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 1:555 W BENJAMIN HOLT DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:209-476-4700
Mailing Address - Fax:209-478-6890
Practice Address - Street 1:2494 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2415
Practice Address - Country:US
Practice Address - Phone:415-821-1200
Practice Address - Fax:415-821-0537
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060952-011223P0300X
CA55105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics