Provider Demographics
NPI:1154645661
Name:KIM, SHIN JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:SHIN
Middle Name:JOSEPH
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 1:1234 BELLINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-2723
Mailing Address - Country:US
Mailing Address - Phone:818-523-7253
Mailing Address - Fax:
Practice Address - Street 1:13128 14TH STREET
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92058
Practice Address - Country:US
Practice Address - Phone:760-763-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7764010-9921-2014040122300000X
CADDS1072301223S0112X
FLDN287611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist