Provider Demographics
NPI:1205565629
Name:KIM, GRACE (DDS)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
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 1:5155 KATELLA AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2957
Mailing Address - Country:US
Mailing Address - Phone:860-405-5915
Mailing Address - Fax:
Practice Address - Street 1:5155 KATELLA AVE APT 309
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90720-2957
Practice Address - Country:US
Practice Address - Phone:860-405-5915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program