Provider Demographics
NPI:1881901619
Name:KIM, KWANG JIB (DDS)
Entity type:Individual
Prefix:DR
First Name:KWANG
Middle Name:JIB
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 1:594 N. INDIAN HILL BLVD.
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5302
Mailing Address - Country:US
Mailing Address - Phone:909-624-3553
Mailing Address - Fax:909-624-3554
Practice Address - Street 1:594 N. INDIAN HILL BLVD.
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5302
Practice Address - Country:US
Practice Address - Phone:909-624-3553
Practice Address - Fax:909-624-3554
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC34861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist