Provider Demographics
NPI:1295979532
Name:MICHELLE K. KIM D.D.S. CORP.
Entity type:Organization
Organization Name:MICHELLE K. KIM D.D.S. CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:KYONGAH
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-449-3367
Mailing Address - Street 1:2245 E. COLORADO BLVD.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-449-3367
Mailing Address - Fax:626-449-3376
Practice Address - Street 1:2245 E. COLORADO BLVD.
Practice Address - Street 2:SUITE 201
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-449-3367
Practice Address - Fax:626-449-3376
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHELLE K. KIM D.D.S. CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-30
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
CA42670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB42670-01OtherMEDICAL