Provider Demographics
NPI:1184335754
Name:JOHNATHAN KIM D.D.S. DENTAL PRACTICE
Entity type:Organization
Organization Name:JOHNATHAN KIM D.D.S. DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:HYUN
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-890-1529
Mailing Address - Street 1:1850 S WATERMAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2852
Mailing Address - Country:US
Mailing Address - Phone:909-890-1529
Mailing Address - Fax:
Practice Address - Street 1:1850 S WATERMAN AVE STE B
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2852
Practice Address - Country:US
Practice Address - Phone:909-890-1529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental