Provider Demographics
NPI:1588387690
Name:KIM, SUNGJUN (DDS)
Entity type:Individual
Prefix:DR
First Name:SUNGJUN
Middle Name:
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 1:11770 RANDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4188
Mailing Address - Country:US
Mailing Address - Phone:909-420-5256
Mailing Address - Fax:
Practice Address - Street 1:7369 DAY CREEK BLVD STE F-103
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-8020
Practice Address - Country:US
Practice Address - Phone:909-646-7902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1081301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice