Provider Demographics
NPI:1417558180
Name:KIM, MARIA ANTONETTE DE LARA (RDH, RDHAP)
Entity type:Individual
Prefix:
First Name:MARIA ANTONETTE
Middle Name:DE LARA
Last Name:KIM
Suffix:
Gender:F
Credentials:RDH, RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 S SAN GORGONIO AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6020
Mailing Address - Country:US
Mailing Address - Phone:951-922-4975
Mailing Address - Fax:951-922-4976
Practice Address - Street 1:66 S SAN GORGONIO AVE STE 5
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6020
Practice Address - Country:US
Practice Address - Phone:951-553-8235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA783124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist