Provider Demographics
NPI:1265594881
Name:HEO-KIM, MI SUNG
Entity type:Individual
Prefix:
First Name:MI SUNG
Middle Name:
Last Name:HEO-KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MI SUNG
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:5814 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4457
Mailing Address - Country:US
Mailing Address - Phone:909-548-4844
Mailing Address - Fax:909-548-0774
Practice Address - Street 1:5814 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4457
Practice Address - Country:US
Practice Address - Phone:909-548-4844
Practice Address - Fax:909-548-0774
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50766122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist