Provider Demographics
NPI:1154578144
Name:KIM, INA (DDS)
Entity type:Individual
Prefix:DR
First Name:INA
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 1:1107 POLYNESIA DR
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1724
Mailing Address - Country:US
Mailing Address - Phone:415-407-5417
Mailing Address - Fax:
Practice Address - Street 1:1598 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4465
Practice Address - Country:US
Practice Address - Phone:510-545-4588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA574491223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics