Healthcare Provider Details

I. General information

NPI: 1043099591
Provider Name (Legal Business Name): HYUN IL KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81812 DR CARREON BLVD STE B
INDIO CA
92201-5594
US

IV. Provider business mailing address

11044 MESQUITE AVE
LOMA LINDA CA
92354-6555
US

V. Phone/Fax

Practice location:
  • Phone: 760-296-1865
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number109358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: