Provider Demographics
NPI:1184799702
Name:KIM, SUSAN JI HYUN (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JI HYUN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11998 FOOTHILL BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:91342-7101
Mailing Address - Country:US
Mailing Address - Phone:818-897-5055
Mailing Address - Fax:818-897-0218
Practice Address - Street 1:11998 FOOTHILL BLVD.
Practice Address - Street 2:
Practice Address - City:LAKE VIEW TERRACE
Practice Address - State:CA
Practice Address - Zip Code:91342-7101
Practice Address - Country:US
Practice Address - Phone:818-897-5055
Practice Address - Fax:818-897-0218
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48731122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist