Provider Demographics
NPI:1811061674
Name:KIM, LISA R (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:R
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1325 N SIERRA BONITA AVE
Mailing Address - Street 2:APT #121
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-8522
Mailing Address - Country:US
Mailing Address - Phone:909-649-5682
Mailing Address - Fax:310-860-9313
Practice Address - Street 1:241 S BEVERLY DR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-3807
Practice Address - Country:US
Practice Address - Phone:310-860-9311
Practice Address - Fax:310-860-9313
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA548501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice