Provider Demographics
NPI:1699940460
Name:KIM, CHANYUL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHANYUL
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 1:3006 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-6129
Mailing Address - Country:US
Mailing Address - Phone:714-828-8275
Mailing Address - Fax:714-828-0508
Practice Address - Street 1:3006 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-6129
Practice Address - Country:US
Practice Address - Phone:714-828-8275
Practice Address - Fax:714-828-0508
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50763122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50763Medicare PIN