Provider Demographics
NPI:1700115342
Name:KIM, SONG KYUN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SONG
Middle Name:KYUN
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 1:4635 E AVENUE S
Mailing Address - Street 2:STE C102-103
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93552
Mailing Address - Country:US
Mailing Address - Phone:661-349-8280
Mailing Address - Fax:
Practice Address - Street 1:4635 E AVENUE S
Practice Address - Street 2:STE C102-103
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93552
Practice Address - Country:US
Practice Address - Phone:661-349-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist