Provider Demographics
NPI:1386250355
Name:KIM, AUDREY BORAHM (DDS)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:BORAHM
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 1:56869 ANTELOPE TRL APT 6
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-2871
Mailing Address - Country:US
Mailing Address - Phone:818-939-1914
Mailing Address - Fax:
Practice Address - Street 1:1ST DENTAL BATTALION/NAVAL DENTAL CENTER
Practice Address - Street 2:ATTN: MEDICAL STAFF SVES; BLDG 2238 A AVE
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5221
Practice Address - Country:US
Practice Address - Phone:818-939-1914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1054741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice