Provider Demographics
NPI:1881923027
Name:KIM, DIANA HYUN (DDS)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:HYUN
Last Name:KIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2926 FANTAIL LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-7813
Mailing Address - Country:US
Mailing Address - Phone:360-265-0000
Mailing Address - Fax:
Practice Address - Street 1:9450 FAIRWAY DR STE 110
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3588
Practice Address - Country:US
Practice Address - Phone:916-740-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1033851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty