Healthcare Provider Details

I. General information

NPI: 1912599457
Provider Name (Legal Business Name): HEOIJIN KIM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W IMPERIAL HWY STE B
LA HABRA CA
90631-0604
US

IV. Provider business mailing address

3540 WILSHIRE BLVD APT 1109
LOS ANGELES CA
90010-3942
US

V. Phone/Fax

Practice location:
  • Phone: 562-690-5729
  • Fax:
Mailing address:
  • Phone: 718-757-0383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7566
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDDS109935
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: