Provider Demographics
NPI:1306900683
Name:KIM, KWANG J (DDS)
Entity type:Individual
Prefix:DR
First Name:KWANG
Middle Name:J
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BEN
Other - Middle Name:KJ
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:10737 CAMINO RUIZ STE 205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2363
Mailing Address - Country:US
Mailing Address - Phone:858-549-7181
Mailing Address - Fax:858-549-1490
Practice Address - Street 1:10737 CAMINO RUIZ
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2359
Practice Address - Country:US
Practice Address - Phone:858-549-7181
Practice Address - Fax:858-549-1490
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA356261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice