Provider Demographics
NPI:1427466598
Name:KIM, DAE HA (DDS)
Entity type:Individual
Prefix:
First Name:DAE
Middle Name:HA
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 1:4301 RENAISSANCE DR
Mailing Address - Street 2:APT 215
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-1505
Mailing Address - Country:US
Mailing Address - Phone:408-439-0538
Mailing Address - Fax:
Practice Address - Street 1:1150 FOXWORTHY AVE STE 10
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-1209
Practice Address - Country:US
Practice Address - Phone:408-439-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-01
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA637551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice