Provider Demographics
NPI:1871964742
Name:KIM, RACHELLE
Entity type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25246 BARTON RD APT 8
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25246 BARTON RD APT 8
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3055
Practice Address - Country:US
Practice Address - Phone:469-396-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEID192910081223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology