Provider Demographics
NPI:1588896740
Name:KIM, JAMES (DDS, MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 S TONOPAH DR
Mailing Address - Street 2:STE. 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:702-291-2031
Mailing Address - Fax:702-366-1483
Practice Address - Street 1:3140 S DURANGO DR
Practice Address - Street 2:STE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-9189
Practice Address - Country:US
Practice Address - Phone:917-407-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58517122300000X, 1223S0112X
CA127414204E00000X
NVS2-141C1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1588896740Medicaid