Provider Demographics
NPI:1700025020
Name:KIM, LUCIO HYUN-CHONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUCIO
Middle Name:HYUN-CHONG
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 E GLENOAKS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-1768
Mailing Address - Country:US
Mailing Address - Phone:818-242-3739
Mailing Address - Fax:818-548-9537
Practice Address - Street 1:620 E GLENOAKS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207-1768
Practice Address - Country:US
Practice Address - Phone:818-242-3739
Practice Address - Fax:818-548-9537
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist