Provider Demographics
NPI:1528155819
Name:KIM, JOHNNY K (DDS)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:K
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 1:936 CRENSHAW BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-1957
Mailing Address - Country:US
Mailing Address - Phone:323-617-4180
Mailing Address - Fax:323-617-4181
Practice Address - Street 1:906 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-3519
Practice Address - Country:US
Practice Address - Phone:323-617-4180
Practice Address - Fax:323-617-4181
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA348601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA34860Medicaid