Provider Demographics
NPI:1972725844
Name:KIM, PETER M (DMD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:KIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 G ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2809
Mailing Address - Country:US
Mailing Address - Phone:661-631-1113
Mailing Address - Fax:661-631-1116
Practice Address - Street 1:2415 G ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2809
Practice Address - Country:US
Practice Address - Phone:661-631-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD28351223P0221X
AZD67191223P0221X
CA560211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM73203050Medicaid
AZ985525Medicaid
AZAZ0158860OtherBCBSAZ