Provider Demographics
NPI:1528802840
Name:KIM, GINA YEAWON (DDS)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:YEAWON
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 1:6859 MAGNOLIA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2866
Mailing Address - Country:US
Mailing Address - Phone:951-682-0810
Mailing Address - Fax:951-289-9552
Practice Address - Street 1:6859 MAGNOLIA AVE STE 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2866
Practice Address - Country:US
Practice Address - Phone:951-682-0810
Practice Address - Fax:951-289-9552
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1101801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice