Provider Demographics
NPI:1912599457
Name:KIM, HEOIJIN (DDS)
Entity Type:Individual
Prefix:
First Name:HEOIJIN
Middle Name:
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 1:3540 WILSHIRE BLVD APT 1109
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3942
Mailing Address - Country:US
Mailing Address - Phone:718-757-0383
Mailing Address - Fax:
Practice Address - Street 1:1701 W IMPERIAL HWY STE B
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-0604
Practice Address - Country:US
Practice Address - Phone:562-690-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV390200000X
NV75661223G0001X
CADDS1099351223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty